Introduction

The prescription of colonoscopies is constantly increasing for the screening and diagnosis of colorectal cancer, precancerous lesions, polyps, and adenomas. Sometimes, indications become excessive due to the availability of this examination on one hand and the fear of missing a neoplastic lesion on the other. The EPAGE II criteria (European Panel on the Appropriateness of Gastrointestinal Endoscopy) was developped to assess the relevance of colonoscopy indications and to rationalize its prescription. The aim of our study was to evaluate the relevance of colonoscopy indications performed in our department according to EPAGE II criteria and to investigate a possible correlation between the appropriateness of the examination and the endoscopic result.

Aims & Methods

A retrospective study was conducted at a hepatogastroenterology department including all colonoscopies performed during the period from January 2022 to June 2023. The relevance of colonoscopy indications according to EPAGE II criteria was classified as appropriate, uncertain, or inappropriate.

Results

The relevance of the indication was evaluated in 406 colonoscopies. The sex ratio (Male / Female) was 1.15. The median age was 51 with an IQ [15.93]. Rectal bleeding represented the most frequently found indications (30%), followed by Crohn's disease (12.8%), then chronic diarrhea (11.1%). 49% of colonoscopies had satisfactory preparation (Boston ≥7). Colonoscopy was complete in 86% of patients, with catheterization of the terminal ileum in 36.2% of cases. A significant endoscopic lesion was found in 63% of colonoscopies, represented mainly by inflammatory lesions of inflammatory bowel disease (20.7%) followed by neoplastic lesions (15.3%) of colorectal cancer, then polyps (10%), benign strictures (6.4%), and diverticulosis (5.7%). Overall, colonoscopy indication was appropriate in 83.5% of cases, uncertain in 10.8%, and inappropriate in 5.7%. A significant endoscopic lesion was found in 63% of patients with an appropriate indication.

Conclusion

The indication for colonoscopies performed in our department was considered appropriate in more than 80% of cases, with rectal bleeding being the main indication. Significant endoscopic lesions were mostly found in cases of appropriate indication, leading us to encourage the use of this software to regulate colonoscopy indications

References

Introduction

Positron emission tomography (PET) scan involves injecting a radioactive isotope (18-fluoro-2-deoxyglucose) to locate areas where the radiotracer accumulates. The established indications of PET scanning mainly concern oncology, where it is used for staging, treatment monitoring, and long-term surveillance. It is also useful in cases of secondary lesions for identifying the primary lesion. Outside of oncology, PET scan has other clinical applications such as diagnosing and monitoring inflammatory diseases, and searching for infectious foci. The incidental discovery of metabolic hyperfixation in the digestive system on PET scan is becoming increasingly common, raising questions about the clinical significance of this hypermetabolism and the need for endoscopic exploration. The aim of our study is to report the endoscopic findings from examinations performed in our department where the indication was the incidental discovery of digestive hypermetabolism on PET scan.

Aims & Methods

This is a descriptive and analytical retrospective monocentric study including all patients referred for endoscopy due to the incidental discovery of digestive metabolic hyperfixation on PET scan, not corresponding to a previously known lesion, between January 2017 and September 2023. Only hypermetabolic fixations located in the stomach, colon, and rectum were included.

Results

28 hypermetabolic fixations were included in the study, of which 46.4% were located in the colon, 42.9% in the rectum, and 10.7% in the stomach. The mean age was 54.9 years with a standard deviation [32,78]. The male-to-female sex ratio was 0.6. PET scan indications were mainly dominated by surveillance of treated cancers or during treatment (57.1%). In 21.4% of cases, PET scan was requested for staging a newly diagnosed tumor, and in 17.9% of patients, it was used to search for a primary tumor with hepatic, pulmonary, or bone metastases. Other indications were rarer, representing 3.6% of cases. Hypermetabolism on PET scan corresponded to a neoplastic lesion in 17.9% of cases, an adenoma in 14.3% of cases, and a benign lesion (non-specific ulceration, inflammatory lesion, or stenosis) in 32.2% of cases. In 35.7% of patients, endoscopic examination did not reveal detectable abnormalities. Hypermetabolism was most often focal (67.9%). According to this study, the presence of focal metabolic hyperfixation was significantly associated with the presence of a neoplastic lesion on digestive endoscopy (P <0.01).

Conclusion

All metabolic hyperfixations on PET scan referred to our endoscopy center underwent endoscopic exploration to rule out a neoplastic lesion. However, additional studies, ideally prospective and multicentric with a larger sample size, are essential to establish the criteria for endoscopic exploration in the case of incidental discovery of digestive hypermetabolism on PET Scan

References

1.Kousgaard SJ, Thorlacius-Ussing O. Incidental colorectal FDG uptake on PET/CT scan and lesions observed during subsequent colonoscopy: a systematic review. Tech Coloproctol. juill 2017;21(7):521-9.
2.van Hoeij FB, Keijsers RGM, Loffeld BC a. J, Dun G, Stadhouders PHGM, Weusten BL a. M. Incidental colonic focal FDG uptake on PET/CT: can the maximum standardized uptake value (SUVmax) guide us in the timing of colonoscopy? Eur J Nucl Med Mol Imaging. janv 2015;42(1):66-71.

Clinical Case Summary

Introduction: ​​​​Blue rubber bleb nevus syndrome or bean’s syndrome, is a rare congenital disorder characterized by the presence of vascular malformations in the skin and other internal organs with a predilection of the gastro intestinal tract. The most common clinical manifestations are gastrointestinal bleeding causing severe iron deficiency anemia, and bluish-purple soft compressible nodules on skin or mucous membranes usually present at birth or during early childhood. We presented a clinical case of upper gastrointestinal bleeding revealing a blue rubber bleb nevus syndrome treated symptomatically with good evolution.
Case Report: A 73 years old woman, who has a history of a gastric and hepatic hemangiomatosis, was hospitalized for 3 months’ history of melena complicated by multiple episodes of hematemesis, with fatigue, pallor and severe anemia. Physical examination revealed small bluish nodules on the trunk, the lower limb and the nose. The abdomen was soft and no tender. Complete blood count revealed a hypochromic microcytic severe anemia with a hemoglobin level of 5.7g/dl. Oesogastroduodenoscopy revealed a large vascular mass in the lower third of the esophagus, with other vascular malformations in the fundus with active bleeding. CT scan of the body revealed the presence of an esophageal large mass extended to the lesser curvature of the stomach with multiple micro calcifications. Cerebral MRI showed no remarkable lesion. The diagnosis of blue rubber bleb nevus syndrome was established based on medical history, cutaneous lesions and the pathognomonic endoscopic lesion. Proton pump inhibitor and blood transfusion, with a regular follow up, treated the patient. The patient presents no other episodes of GI bleeding during the hospital stay and was discharged with a hemoglobin level of 10g/dl.

References

[1] Moodley M, Ramdial P. Blue rubber bleb nevus syndrome: case report and review of the literature. Pediatrics 1993; 92: 160–162.
[2] Cho YM, Steen C, James J. Blue rubber bleb nevus syndrome: a rare cause of abdominal pain. ANZ J Surg 2020; 90: 619–621.
[3] Xia H, Wu J, Huang Y. Blue rubber bleb nevus syndrome: a single-center case series in 12 years. Transl Pediatr 2021; 10: 2960–2971.
[4] Rodrigues D, Bourroul ML, Ferrer AP, et al. Blue rubber bleb nevus syndrome. Rev Hosp Clin Fac Med Sao Paulo 2000; 55: 29–34.
[5] Soblet J, Kangas J, Nätynki M, et al. Blue Rubber Bleb Nevus (BRBN) Syndrome Is Caused by Somatic TEK (TIE2) Mutations. Journal of Investigative Dermatology 2017; 137: 207–216.
[6] Tang X, Gao J, Yang X, et al. A 10-year delayed diagnosis of blue rubber bleb nevus syndrome characterized by refractory iron-deficiency anemia. Medicine (Baltimore) 2018; 97: e10873.
[7] Shin SH, Chae HS, Ji JS, et al. A case of blue rubber bleb nevus syndrome. Korean J Intern Med 2008
[8] Tyrrel RT, Baumgartner BR, Montemayor KA. Blue rubber bleb nevus syndrome: CT diagnosis of intussusception. AJR Am J Roentgenol 1990

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Introduction

Gastric cancer is the 5^th most common cancer globally(1). Europe's Beating Cancer Plan recognises the urgent need for a gastric cancer screening strategy(2). One promising approach, outlined in the Maastricht VI/Florence consensus report, suggests integrating screening modalities for gastric cancer, such as gastroscopy with colorectal cancer screening (3). This method holds the potential for cost-saving benefits through combined screening efforts (4).

Aims & Methods

We aimed to determine the prevalence of preneoplastic and neoplastic lesions in a high-risk age group, in those who underwent gastroscopy at the time of colonoscopy. Our secondary aims were to determine a)the quality of endoscopy performed and b) the endoscopic burden for pathology that required follow-up.
This was a single-centre review and audit of key performance indicators in a colorectal cancer screening centre. The age group targeted was 50-74, i.e. the target group for colon cancer screening in Europe. We included those undergoing colonoscopy for polyp surveillance or as part of the national colon cancer screening programme. Participants with red flag symptoms (iron deficiency anaemia, weight loss, dysphagia), family history of gastric cancer, established diagnosis of Barrett’s, intestinal metaplasia, dysplasia or who had a gastroscopy in the last 3 years were excluded. The sample size required for a 95% confidence interval with a presumed positivity rate of 5-7% was 101. Descriptive statistics, correlations and associations were examined using Stata software.

Results

101 patients were included; the median age was 59;38% were male. Indications for gastroscopy included abdominal pain (45%), chronic reflux (37%), chronic dyspepsia (7%) and other (9%). All patients had a technically complete gastroscopy (D2 intubation rate 100%, retroflexion 100%), the median procedure length was 7 minutes(range 4-21). 93% of patients had a macroscopic finding at the time of gastroscopy. Findings included gastritis(chronic superficial, chemical)(60%), hiatus hernia (50%), oesophagitis (28%), duodenitis (24%), gastric body polyps (10%), Barrett’s mucosa (8%), benign gastric or duodenal ulceration(9%), Schatzki ring (4%), erosions (4%), intestinal metaplasia (IM)(1%), oesophageal candidiasis (1%) and varices (1%). 59% had biopsies taken from two topographical sites as per MAPS guidelines. On biopsy, Helicobacter pylori infection was found in 15% (15/101), 7% had intestinal metaplasia(IM); no atrophy, dysplasia or cancer was detected. In those with IM who had MAPS biopsies (5/7), all were focal IM. In those with suspected Barrett’s (n=8), 88% had biopsies taken in accordance with the Seattle protocol and the Prague classification was used in 50% of cases. Additional pathology encountered included histological evidence of antral gastritis (56%), body gastritis (53%), reflux oesophagitis (21%), Barrett’s without dysplasia (4%), duodenitis (3%), and eosinophilic oesophagitis (1%). There was no statistical difference in age (p<0.82) or gender (p<0.32)in those with preneoplastic changes on gastroscopy.

Conclusion

11% of individuals within the target age bracket exhibited a pre-neoplastic condition on gastroscopy and/or histology (i.e. gastric intestinal metaplasia, gastric atrophy or Barrett's oesophagus), a further 15% were diagnosed and treated for Helicobacter pylori infection, the leading cause of gastric cancer. Among these cases, 4-7% necessitated subsequent surveillance gastroscopy. Our findings support the role of dual endoscopic screening with quality gastroscopy as a potential strategy for gastric cancer screening.

References

1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-49. doi: 10.3322/caac.21660. Epub 2021 Feb 4.
2. Commission E. Europe's Beating Cancer Plan - Communication from the commission to the European Parliament and the Council. 2021.
3. Malfertheiner P, Megraud F, Rokkas T, Gisbert JP, Liou JM, Schulz C, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022.
4. Libanio D, Antonelli G, Marijnissen F, Spaander MC, Hassan C, Dinis-Ribeiro M, Areia M. Combined gastric and colorectal cancer endoscopic screening may be cost-effective in Europe with the implementation of artificial intelligence: an economic evaluation. Eur J Gastroenterol Hepatol. 2024;36(2):155-61. doi: 10.1097/MEG.0000000000002680. Epub 2023 Nov 15.