Clinical Case Summary

The term mucosal prolapse polyps (MPP) is used to describe a group of rare colonic lesions that are part of the mucosal prolapse syndrome. They often pose a challenge for gastroenterologists due to their macroscopic similitude to adenomatous polyps and even neoplastic lesions, leading to unnecessary procedures for their removal.

We present the case of a 48-year old woman who underwent colonoscopy for rectal bleeding. Two nodular erythematous lesions of 8’5x4cm, stiff to touch, were identified in the recto-sigmoid. A biopsy was performed twice, showing no histological characterization. Thus, and due to the impossibility of carrying out an endoscopic resection because of their size and uncertain histological nature of the lesions, a trans-anal surgical resection was performed, this time being the histological characterization positive for inflammatory polyp with mucosal prolapse features.

MPP are extremely rare. The biggest case report series to date by Tendler et al. only features 15 cases. Due to the scarcity of published data, MPP’s prevalence and etiology are unclear, though there seems to be an association with constipation and diverticular disease. Their most common clinical presentation is rectal bleeding, although they can remain asymptomatic for years. The endoscopical image is an excrescent, hyperemic lesion, showing the annual tree ring sign, which is relatively new to gastroenterologists. There have been no reported cases where MPP have been a precursor lesion of malignancy.

A high fiber diet should be considered in asymptomatic pacients. In case of recurrent bleeding, an endoscopic or surgical removal seems reasonable depending on the center's experience.

In conclusion, the diagnosis of MPP could be challenging due to to the similarities with other lesions. Gastroenterologists and pathologists should take into account this entity into their differencial diagnosis when facing this kind of lesions to provide efficient healthcare assistance.

References

Tendler DA et al. Prolapsing mucosal polyps: an underrecognized form of colonic polyp--a clinicopathological study of 15 cases. Am J Gastroenterol. 2002 Feb;97(2):370-6. doi: 10.1111/j.1572-0241.2002.05472.x. PMID: 11866275 Libânio D, Meireles C, Afonso LP, Henrique R, Pimentel-Nunes P, Dinis-Ribeiro M. Mucosal Prolapse Polyp Mimicking Rectal Malignancy: A Case Report. GE Port J Gastroenterol. 2016 Feb 18;23(4):214-217. Wong YP, Kabincong C, Jabar MF, Tan GC. Rectal Polyposis in Mucosal Prolapse Syndrome. Diagnostics (Basel). 2022 Apr 12;12(4):966. nEinoder SH, Thomson ACM, Urquhart P, Smart PJ. Prolapsing mucosal fold: largest reported, presenting with major haemorrhage. J Surg Case Rep. 2018 Nov 22;2018(11):rjy312. Prolapsing mucosal polyp: A form of colonic polyp not to be forgotten. Revista de Gastroenterología de México (English Edition), Volume 84, Issue 3, July–September 2019, Pages 407-409. R. Monreal-Robles, J.A. González-González, D.E. Benavides-Salgado, H.J. Maldonado-Garza Huang CC, Frankel WL, Doukides T, Zhou XP, Zhao W, Yearsley MM. Prolapse-related changes are a confounding factor in misdiagnosis of sessile serrated adenomas in the rectum. Hum Pathol. 2013 Apr;44(4):480-6. R. Monreal-Robles, J.A. et al. Prolapsing mucosal polyp: A form of colonic polyp not to be forgotten. Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario «Dr. José E. González» México

Introduction

Endoscopic ultrasound-guided tissue acquisition, including both fine needle aspiration (EUS-FNA) and fine needle biopsy (EUS-FNB), has been widely performed to obtain samples from pancreatic and non-pancreatic lesions.^{1, 2} The impact of the diagnostic yield between FNA and FNB remains unclear.

Aims & Methods

We conducted this study to compare the diagnostic performance and accuracy of the 22-gauge FNA needles with the 22-gauge FNB needles in sampling solid pancreatic and non-pancreatic lesions. This is a prospective multicenter study conducted on 465 cases presented with solid pancreatic or non-pancreatic lesions.

Results

Patients were 275 male and 190 females with a mean age of 59 years. Three hundred twenty-seven patients had solid pancreatic lesions, while 138 had non-pancreatic lesions; 245 cases underwent EUS-FNA, and the remaining 211 cases underwent EUS-FNB. The presence of intact tissue core and sample adequacy were significantly higher in the FNB cases in solid pancreatic and non-pancreatic lesions. Blood contamination was significantly more in cell blocks and smears of EUS-FNA compared to that of EUS-FNB in solid pancreatic and non-pancreatic lesions. Based on histologic assessment of cell block only, EUS-FNB had more diagnostic accuracy (99%) than FNA (61%) (P-value<0.005). However, cytological diagnosis by smears only showed no significant difference. The combined cytological and histological evaluation had 100% sensitivity, specificity, and accuracy.

Conclusion

EUS-FNA and EUS-FNB have comparable accuracy in diagnosing solid pancreatic and non-pancreatic lesions without ROSE. EUS-FNB is superior to EUS-FNA in acquiring intact tissue core and adequate samples with little blood contamination. Based on histological assessment (cell block/tissue core) only, EUS-FNA has less accuracy than EUS-FNB in diagnosing solid pancreatic lesions.

References

1. Wani S, Muthusamy VR, McGrath CM, et al. AGA white paper: opti- mizing endoscopic ultrasound-guided tissue acquisition and future di- rections. Clin Gastroenterol Hepatol 2018; 16: 318-27.

1. Wong T, Pattarapuntakul T, Netinatsunton N, et al. Diagnostic performance of endoscopic ultrasound-guided tissue acquisition by EUS-FNA versus EUS-FNB for solid pancreatic mass without ROSE: a retrospective study. World J Surg Oncol. 2022; 20(1): 215. doi:10.1186/s12957-022-02682-3.

Introduction

The incidence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD) are notably higher in individuals diagnosed with type 2 diabetes mellitus (T2DM). However, studies evaluating the progression of MASLD in patients with T2DM and normal serum aminotransferase (ALT) levels are limited.

Aims & Methods

This 5-year prospective cohort study aimed to evaluate the progression of MASLD in T2DM patients with normal ALT. People with type 2 diabetes who had MASLD (defined by controlled attenuation parameter (CAP) >250 dB/min) and ALT levels that stayed normal (defined by ALT ≤40 IU/L for at least two occasions spanning at least six months) at Rajavithi Hospital, Bangkok, from November 2016 to 2017 were included. We excluded patients with viral hepatitis and alcohol consumption exceeding moderate levels. Transient elastography (TE) and CAP measurements were performed at baseline and ≥5 years of follow-up. The cutoffs to define significant and advanced fibrosis were TE >8 kPa and TE >12 kPa, respectively. All patients were instructed to reduce their weight and abstain from herbal remedies; medications for comorbidities were prescribed without limitations, subject to the physician's assessment. (most patients were under endocrinologist care.)

Results

The study included 84 patients, 57% of whom were female and had a mean age of 58.5 years. Of these, 62% were obese, with a mean BMI of 28.6 kg/m2. At baseline, the median TE was 6.92±3.35 kPa; 57 (68%) had no significant fibrosis, 22 (26%) had significant fibrosis, and 5 (6%) had advanced fibrosis, and after a 5-year follow-up, the median TE was 6.54±3.57 kPa; 69 (82%) had no significant fibrosis, 15 (18%) had significant fibrosis, and 2 (2%) had advanced fibrosis. During the follow-up, fibrosis decreased in 45 (54%), remained stable in 6 (7%), and increased in 33 (39%) patients, while a small proportion of patients experienced changes in the stages of fibrosis: 1.2% progressed from significant to advanced fibrosis; 17.4% regressed from advanced to significant fibrosis or transitioned from significant to no fibrosis; 12.8% remained stable with significant and advanced fibrosis; and the majority (66.3%) remained without significant fibrosis. A significant factor associated with fibrosis progression was alcohol consumption (p=0.013), while the use of angiotensin receptor blockers (p=0.042) was associated with fibrosis regression. Significant factors associated with steatosis progression included high baseline BMI (p=0.013), an increase in BMI ≥ 5% (p=0.04), high fasting plasma glucose, and LDL cholesterol levels, while a decrease in BMI ≥ 5% (p=0.002) the use of calcium channel blockers (p=0.038) and coffee consumption >3 cups per day (p=0.031) were associated with steatosis regression. ALT elevation during the follow-up occurred in a small proportion of patients, and it was not significantly associated with fibrosis or steatosis progression.

Conclusion

The majority of MASLD patients with T2DM and normal ALT maintained a relatively stable liver disease during 5 years of follow-up. Obesity, weight gain, alcohol consumption, and inadequate metabolic control were all associated with the progression of MASLD, whereas weight loss, coffee consumption, angiotensin receptor blockers, and calcium channel blockers were all associated with the improvement of MASLD.

Disclosure

I have nothing to disclose