Gastric heterotopia in the rectum: a rare entity with potential pitfalls.

Gastric heterotopia (GHT) is a medical condition where the gastric mucosa is found at a non-phyysiological part of the body. GHT can present itself anywhere in the gastrointestinal tract from the mouth to the anorectal area, as well as in the hepatobiliary system. However, it is relatively rare to find GHT in the rectum, with only around 50 documented cases reported in medical literature. We present the case of a 51-year-old man who underwent average-risk screening colonoscopy. He had no clinically significant comorbidities and was otherwise asymptomatic, with no family history. Notable findings included a pseudopolypoid lesion in the distal rectum, adjacent to the dentate line, measuring approximately 15 mm with regular-appearing mucosa under narrow-band-imaging. Biopsy specimens showed histological characteristics of oxyntic-type gastric mucosa without inflammation or dysplasia. GHT has the potential to progress to malignancy, although the rate of malignancy is currently unknown. Awareness of this entity is important given its frequency and potential for misdiagnosis.

Portal air embolism after endoscopic retrograde cholangiopancreatography.

The authors present an uncommon case of portal venous gas and contrast opacification that occured during endoscopic retrograde cholangiopancreatography. This report demonstrates that portal vein cannulation may be a source of confusion because the guided wire trajectory inside the portal vein may be similar to that of the biliary, and a contrast washout/opacified portal vein may be misinterpreted as an incompletely filled bile duct.

Infective Endocarditis After Endoscopic Stricture Dilation in Crohn's Disease.

Stricture formation is common in Crohn's disease, and endoscopic intervention plays an increasingly important role in managing these strictures. A 61-year-old man with biological aortic prosthesis and a 30-year history of ileocolonic stricturing Crohn's disease, managed with azathioprine and infliximab, presented with marked occlusive symptoms. Colonoscopy revealed a descending colon stricture, prompting endoscopic balloon dilation. At the time of the procedure, no prophylactic antibiotic was given. Subsequently, he developed Streptococcus gallolyticus endocarditis, necessitating aortic valve replacement. The authors present a case of late Streptococcus gallolyticus endocarditis associated with endoscopic balloon dilation of a Crohn-related colonic stricture.

Management of colorectal laterally spreading tumors: a systematic review and meta-analysis.

Objective and study aims To evaluate the efficacy and safety of different endoscopic resection techniques for laterally spreading colorectal tumors (LST). Methods Relevant studies were identified in three electronic databases (PubMed, ISI and Cochrane Central Register). We considered all clinical studies in which colorectal LST were treated with endoscopic resection (endoscopic mucosal resection [EMR] and/or endoscopic submucosal dissection [ESD]) and/or transanal minimally invasive surgery (TEMS). Rates of en-bloc/piecemeal resection, complete endoscopic resection, R0 resection, curative resection, adverse events (AEs) or recurrence, were extracted. Study quality was assessed with the Newcastle-Ottawa Scale and a meta-analysis was performed using a random-effects model. Results Forty-nine studies were included. Complete resection was similar between techniques (EMR 99.5 % [95 % CI 98.6 %-100 %] vs. ESD 97.9 % [95 % CI 96.1 - 99.2 %]), being curative in 1685/1895 (13 studies, pooled curative resection 90 %, 95 % CI 86.6 - 92.9 %, I 2  = 79 %) with non-significantly higher curative resection rates with ESD (93.6 %, 95 % CI 91.3 - 95.5 %, vs. 84 % 95 % CI 78.1 - 89.3 % with EMR). ESD was also associated with a significantly higher perforation risk (pooled incidence 5.9 %, 95 % CI 4.3 - 7.9 %, vs. EMR 1.2 %, 95 % CI 0.5 - 2.3 %) while bleeding was significantly more frequent with EMR (9.6 %, 95 % CI 6.5 - 13.2 %; vs. ESD 2.8 %, 95 % CI 1.9 - 4.0 %). Procedure-related mortality was 0.1 %. Recurrence occurred in 5.5 %, more often with EMR (12.6 %, 95 % CI 9.1 - 16.6 % vs. ESD 1.1 %, 95 % CI 0.3 - 2.5 %), with most amenable to successful endoscopic treatment (87.7 %, 95 % CI 81.1 - 93.1 %). Surgery was limited to 2.7 % of the lesions, 0.5 % due to AEs. No data of TEMS were available for LST. Conclusions EMR and ESD are both effective and safe and are associated with a very low risk of procedure related mortality.

Variation between Pathological Measurement and Endoscopically Estimated Size of Colonic Polyps.

BACKGROUND AND AIMS: Accurate determination of colonic polyp size is vital to an appropriate surveillance. The main aim of this study was to evaluate variation between the polyp size reported by the endoscopist and its pathological measurement. METHODS: A retrospective analysis of all colonic adenomatous polyps resected in a 12-month period was performed at our center. Endoscopic and pathological size for each polyp were compared, and overestimation rates, underestimation rates, and endoscopic-pathological variation (EPV) were calculated. RESULTS: Among the 573 polyps that were included, the mean endoscopic and pathological sizes were 8.00 and 6.66 mm, respectively. The most frequent error, in 62.1%, was overestimation by the colonoscopist. Overestimation and EPV were associated with resection technique (higher in endoscopic mucosal resection and smaller with biopsy forceps) and colonoscopist. They were not associated with years of experience in colonoscopy. Overestimation was more frequent in larger polyps. CONCLUSIONS: Our study shows significant discordance between endoscopic and pathological size of colonic polyps with a clear tendency for endoscopic overestimation. Larger polyps are more difficult to accurately assess than smaller ones. This propensity for error was not related to colonoscopist's years of experience and seems to be an individual tendency.

INTRODUÇÃO E OBJETIVOS: A precisão na determinação do tamanho de pólipos do cólon é vital para uma vigilância adequada. O objetivo deste trabalho foi avaliar a variação entre o tamanho reportado pelo endoscopista e pelo anatomo-patologista. MÉTODOS: Foi realizada uma análise retrospetiva de todos os pólipos adenomatosos ressecados, num período de 12 meses, no nosso centro. O tamanho endoscópico e patológico de cada pólipo foi comparado e foram calculadas as taxas de sobrestimativa, subestimativa e a variação endoscópica-patológica (VEP). RESULTADOS: Foram incluídos 573 pólipos, tamanho endoscópico e patológico médio de 8,00 e 6,66 milímetros, respetivamente. O erro mais frequente, em 62.1% foi a sobrestimativa pelo endoscopista. A sobrestimativa e a VEP associaram-se à técnica de resseção (maior na resseção endoscópica da mucosa e mais pequena na pinça de biópsias) e ao colonoscopista. Não se associaram aos anos de experiáncia em colonoscopia. A sobrestimativa foi mais frequente nos pólipos maiores. CONCLUSÕES: O nosso trabalho mostrou uma discordância significativa entre o tamanho endoscópico e patológico de pólipos do cólon com uma clara tendáncia para a sobrestimativa. Os pólipos maiores são mais difíceis de avaliar com precisão do que os mais pequenos. Esta propensão para o erro não se relacionou com os anos de experiáncia em colonoscopia e parece ser uma tendáncia individual.

Narrow-Band Imaging: Clinical Application in Gastrointestinal Endoscopy.

Narrow-band imaging is an advanced imaging system that applies optic digital methods to enhance endoscopic images and improves visualization of the mucosal surface architecture and microvascular pattern. Narrow-band imaging use has been suggested to be an important adjunctive tool to white-light endoscopy to improve the detection of lesions in the digestive tract. Importantly, it also allows the distinction between benign and malignant lesions, targeting biopsies, prediction of the risk of invasive cancer, delimitation of resection margins, and identification of residual neoplasia in a scar. Thus, in expert hands it is a useful tool that enables the physician to decide on the best treatment (endoscopic or surgical) and management. Current evidence suggests that it should be used routinely for patients at increased risk for digestive neoplastic lesions and could become the standard of care in the near future, at least in referral centers. However, adequate training programs to promote the implementation of narrow-band imaging in daily clinical practice are needed. In this review, we summarize the current scientific evidence on the clinical usefulness of narrow-band imaging in the diagnosis and characterization of digestive tract lesions/cancers and describe the available classification systems.

O sistema de iluminação narrow-band imaging é um sistema de imagem avançada que utiliza ferramentas digitais óticas para realçar imagens endoscópicas e melhorar a observação da superfície e do padrão microvascular da mucosa. O narrow-band imaging tem demonstrado ser um importante adjuvante à endoscopia com luz branca, melhorando a deteção de lesões no tubo digestivo. Tam-bém, possibilita a distinção entre lesões benignas e mali-gnas, guia as biópsias para zonas suspeitas, prediz o risco de cancro invasivo, delimita as margens de ressecção e identifica lesões residuais em cicatrizes. Portanto, em mãos experientes, é uma ferramenta útil que permite ao médico decidir o melhor tratamento (endoscópico ou cirúrgico) e orientação. A evidência atual sugere que esta técnica deve ser utilizada por rotina em doentes com risco aumentado para lesões neoplásicas do tubo digestivo e poderá tornar-se o método de escolha num futuro próxi-mo, pelo menos nos centros de referência. Contudo, são necessários programas de treino adequados para pro-mover a utilização do narrow-band imaging na prática clinica diária. Nesta revisão, resumimos a evidência científi-ca disponível acerca da utilidade do narrow-band imaging no diagnóstico e caracterização das lesões do tubo di-gestivo e descrevem-se os sistemas de classificação dis-poníveis.

Common Variable Immunodeficiency with Several Gastrointestinal Manifestations.

Common variable immunodeficiency (CVID) is an immunodeficiency disorder with a high incidence of gastrointestinal (GI) manifestations and an increased risk of gastric malignancy. We report a case of a CVID with mild anemia presenting with multiple GI manifestations: gastric low-grade dysplasia (LGD), enteropathy with villous atrophy, refractory Giardia infection, nodular lymphoid hyperplasia, and inflammatory bowel-like disease. The differential diagnosis with celiac sprue could be challenging because of CVID enteropathy with villous flattening. Gastric LGD in a patient with an increased risk for gastric malignancy makes the appropriate surveillance of gastric cancer in CVID challenging.

Splenic Rupture as a Complication of Colonoscopy.

Splenic rupture is a rare but serious complication after colonoscopy, with high global mortality (5%). Diagnosis requires a high index of suspicion because presentation can be subtle, nonspecific, and delayed from hours to days and then not easily attributed to a recent endoscopy. Urgent splenectomy is the most common treatment option. A 73-year-old woman was admitted to the emergency department 8 h following a diagnostic colonoscopy. She presented abdominal pain and syncope. The diagnosis of splenic rupture was made and a splenectomy was urgently performed. The patient's postoperative recovery was uneventful. Splenic rupture is a rare complication of colonoscopy which cannot be underestimated in the differential diagnosis of abdominal pain after this procedure. Splenic injuries may occur in apparently uncomplicated, easy colonoscopies performed by experienced endoscopists, with no risk factors identified, as in this case.

A rotura esplénica é uma complicação rara da colonoscopia mas potencialmente fatal, apresentando uma mortalidade global de 5%. O diagnóstico desta entidade requer um alto índice de suspeição uma vez que a apresentação clínica pode ser subtil, inespecífica e com início tardio, horas ou dias após o exame, dificultando a associação dos sintomas a uma possível complicação da colonoscopia recente. A primeira opção terapêutica é a esplenectomia urgente. Apresentamos o caso de uma mulher com 73 anos que foi admitida no serviço de urgência 8 h após a realização de uma colonoscopia por dor abdominal e síncope. O diagnóstico de rotura esplénica foi feito e a doente foi submetida de forma urgente a uma esplenectomia. Não ocorreram intercorrências no período pós-operatório. A rotura esplénica é uma complicação rara da colonoscopia e não deve ser esquecida como um diagnóstico diferencial de dor abdominal com início após a colonoscopia. A rotura esplénica pode ocorrer em colonoscopias aparentemente fáceis, realizadas por gastrenterologistas experientes e em doentes sem fatores de risco identificados, como o caso que se apresenta.

A Case Series of Anal Carcinoma Misdiagnosed as Idiopathic Chronic Anal Fissure.

Chronic anal fissure is a linear ulcer in the anal canal that has not cicatrized for more than 8-12 weeks of treatment. Most anal fissures are idiopathic and are located in the posterior midline. Squamous cell carcinoma of the anus commonly presents as bleeding and anal pain. It may also present as a mass, nonhealing ulcer, itching, discharge, fecal incontinence and fistulae. Not uncommonly, small and early cancers are misdiagnosed as benign anorectal disorders like anal fissures or hemorrhoids. The clinical suspicion of squamous cell carcinoma of the anus is of paramount importance in patients with nonhealing anal fissures, fissures in atypical positions or with indurated or ulcerated anal tags and in patients with risk factors for the development of anal squamous intraepithelial lesions that are precursors of invasive anal squamous cell carcinoma. The authors present 3 cases of squamous cell carcinoma of the anus initially misdiagnosed as benign chronic anal fissure.

A fissura anal crónica é uma úlcera linear presente no canal anal que não cicatriza após 8 a 12 semanas de tratamento. A maioria das fissuras anais são idiopáticas e localizadas na linha média posterior. O carcinoma epidermoide do canal anal apresenta-se frequentemente com proctalgia e hemorragia, podendo também manifestar-se como uma úlcera que não cicatriza, corrimento anal, incontinência fecal e fístula. Não raramente, os carcinomas pequenos e em estádios precoces podem ser diagnosticados incorretamente como patologia anorrectal benigna, como fissuras ou hemorróidas. A suspeição clínica de carcinoma epidermoide do canal anal é de enorme importância em fissuras anais que não cicatrizam, localizadas em posições atípicas, com marisca anal ulcerada ou endurecida e em doentes com fatores de risco para lesões escamosas intraepiteliais anais que são percursoras do carcinoma epidermoide anal. Os autores apresentam três casos de carcinoma epidermoide do canal anal inicialmente diagnosticados incorretamente como fissuras anais benignas.

Long-term outcomes of Botulinum toxin in the treatment of chronic anal fissure: 5 years of follow-up.

BACKGROUND: Chronic anal fissure is a frequent and disabling disease, often affecting young adults. Botulinum toxin and lateral internal sphincterotomy are the main therapeutic options for refractory cases. Botulinum toxin is minimally invasive and safer compared with surgery, which carries a difficult post-operative recovery and fecal incontinence risk. The long-term efficacy of Botulinum toxin is not well known. OBJECTIVE: The aim of this study was to evaluate the long-term efficacy and safety of Botulinum toxin in the treatment of chronic anal fissure. METHODS: This was a retrospective study at a single center, including patients treated with Botulinum toxin from 2005 to 2010, followed over at least a period of 5 years. All patients were treated with injection of 25U of Botulinum toxin in the intersphincteric groove. The response was registered as complete, partial, refractory and relapse. RESULTS: Botulinum toxin was administered to 126 patients, 69.8% (n = 88) were followed over a period of 5 years. After 3 months, 46.6% (n = 41) had complete response, 23.9% (n = 21) had partial response and 29.5% (n = 26) were refractory. Relapse was observed in 1.2% (n = 1) at 6 months, 11.4% (n = 10) at 1 year, 2.3% (n = 2) at 3 years; no relapse at 5 years. The overall success rate was 64.8% at 5 years of follow-up. Botulinum toxin was well tolerated by all patients and there were no complications. CONCLUSION: The use of Botulinum toxin to treat patients with chronic anal fissure was safe and effective in long-term follow-up.

Black Anal Canal: Acute Necrosis.

Acute ischemia of the rectum or anal canal resulting in necrosis is extremely uncommon because both the rectum and the anal canal have excellent blood supplies. We present a case with spontaneous necrosis of the anal canal without rectal involvement. Surgical debridement was accomplished, and the recovery was uneventful. The patient was elderly, with probable atherosclerotic arterial disease, and presented with hypotension. Due to the lack of other precipitating factors, the hypoperfusion hypothesis seems to be the most suitable in this case. To the best of our knowledge, no similar cases have been reported in the literature on this subject.

Schwannoma-A Rare Subepithelial Lesion of the Colon.

Schwannoma is a benign tumor arising from Schwann cells that form the neural sheath. Primary schwannoma of the colon is rare and a few cases have been reported. We report a case of schwannoma of the colon and present the differential diagnosis that must be considered in the evaluation of colonic subepithelial lesions.

O schwannoma é um tumor benigno com origem nas células de Schwann que formam as bainhas nervosas. O schwannoma primário do cólon é uma lesão rara e poucos casos foram descritos. Apresenta-se o caso de um schwannoma do cólon e faz-se referência aos diagnósticos diferenciais que devem ser considerados na avaliação das lesões subepiteliais do cólon.

Portal air embolism after endoscopic retrograde cholangiopancreatography

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