Outcomes of Gallbladder Polyps and Their Association With Gallbladder Cancer in a 20-Year Cohort.

Importance: Gallbladder polyps (GP) are found in more than 4% of adult abdominal ultrasonographs. Their growth pattern and association with gallbladder cancer (GBC) are poorly defined. Objective: To determine the growth pattern of GPs and their association with GBC. Design, Setting, and Participants: This cohort study included 622 227 adult members (ie, aged 18 years or older) of Kaiser Permanente Northern California, an integrated health care delivery system, enrolled between January 1, 1995, and December 31, 2014. The GBC cohort comprised a total of 365 adults with GBC and prior ultrasonography, and the GP cohort comprised 35 970 adults with GPs present on ultrasonography. Data analysis was performed from March 2016 to November 2019. Exposures: Gallbladder polyps (quantitative size, <6 mm, 6 to <10 mm, and ≥10 mm or qualitative size [ie, tiny, small, moderate, and large]). Main Outcomes and Measures: For the GBC cohort, proportion of patients with GBC with polyps identified on preceding ultrasonograph. For the GP cohort, rates of GBC among those with polyps according to size and rate of GP growth of at least 2 mm over time. Results: The GBC cohort comprised 365 individuals (267 [73.1%] women; 173 [47.4%] white patients; median [interquartile range] age, 71 [61-79] years). After excluding 14 patients who did not have evaluation of polyp size, the final GP cohort comprised 35 856 adults, with 18 645 (52.0%) women, a median (interquartile range) age 50 (40-60) years, and 15 573 (43.3%) white patients. Gallbladder polyps were found in 22 patients (6.0%) in the GBC cohort and in 35 870 of 622 227 adults (5.8%) who underwent abdominal ultrasonography. Of these, 19 (0.053%) were diagnosed with GBC, similar to those without GP (316 of 586 357 [0.054%]). The unadjusted GBC rate per 100 000 person-years was 11.3 (95% CI, 6.2-16.3) overall and increased with polyp size, from 1.3 (95% CI, 0-4.0) with initial size of less than 6 mm (n = 17 531) to 128.2 (95% CI, 39.4-217.0) with initial size of 10 mm or larger (n = 2055). In those observed for at least 1 year, the rate was 3.6 (95% CI, 0.7-6.5) per 100 000 person-years. In 6359 patients with evaluable follow-up, unadjusted cumulative probabilities of polyp growth of at least 2 mm at 10 years were 66.2% (95% CI, 62.3%-70.0%) in polyps initially less than 6 mm and 52.9% (95% CI, 47.1%-59.0%) in polyps initially 6 mm to less than 10 mm. Conclusions and Relevance: In this study, GBC rates were low and similar among patients with and without GPs. Growth of 2 mm or more appeared to be part of GP natural history. The results call into question the strategy of proactively following GP to detect GBC.

Case of pediatric traditional serrated adenoma resected via endoscopic submucosal dissection.

Traditional serrated adenoma (TSA) is a type of serrated polyp of the colorectum and is thought to be a precancerous lesion. There are three types of serrated polyps, namely, hyperplastic polyps, sessile serrated adenomas/polyps, and TSAs. TSA is the least common of the three types and accounts for about 5% of serrated polyps. Here we report a pediatric case of TSA that was successfully resected by endoscopic submucosal dissection (ESD). This rare case report describes a pediatric patient with no family history of colonic polyp who was admitted to our hospital with hematochezia. On colonoscopy, we found a polypoid lesion measuring 10 mm in diameter in the lower rectum. We selected ESD as a surgical option for en bloc resection, and histopathological examination revealed TSA. The findings in this case suggest that TSA with precancerous potential can occur in children, and that ESD is useful for treating this lesion.

Screening for colorectal cancer.

Screening for cancer is performed in order to detect unsuspected cancers in an asymptomatic population. Screening is justified for the detection of precancer and cancer when the screening test is safe and the disease has a prevalence that justifies the cost and also when testing has low rates of false positive results. Screening can lead to the early diagnosis of specific cancers which, when treated, can result in a prolonged life span. Colorectal cancer is the third-most common form of cancer in the Western world. Many of these cancers are thought to arise from precancerous lesions in the colon, such as adenomatous polyps. The specific advantage of colorectal cancer screening include the earlier detection of such cancers, the detection of benign conditions such as polyps that can predispose to cancer and the potential for earlier and curative therapy in these patients. Screening for colorectal cancer is indicated where life expectantly is greater then five years and, in general, for people under 75 years of age.

Pitfalls and feasibility of a protocol of virtual colonography designed for the screening of colo-rectal pre-cancerous lesions.

PURPOSE: To evaluate the pitfalls occurring during the virtual colonoscopy examination performed with a protocol designed for screening purposes. MATERIALS AND METHODS: 40 patients underwent a spiral CT for virtual colonoscopic evaluation with the following parameters: collimation 3 mm, feed 6 mm.rot(-1), pitch 2 and increment 1 mm in supine position. Virtual colonography examination was carried out using a dedicated workstation equipped with a software which allows to generate 3D images and virtual endoscopic views. Colon distension, fluid and fecal material were assessed on a 3 point scale. RESULTS: Distension score was 0.50. Left colon and cecum score was 0.32 while in the sigmoid and rectum the score was worse with 0.86. Fluid and fecal residues scores were 0.31 and 0.19 respectively. On almost half of the patients additional scans would be necessary. The main cause of additional scans is suboptimal intestinal preparation and colon distension. CONCLUSION: The use of virtual colonoscopy for screening purposes will be possible through the further technical development and with the optimisation of the protocols, particularly by the improvement of colon cleansing and distension.

Polypoid and pseudopolypoid lesions of inflammatory bowel disease: diagnosis on double-contrast enema.

The radiological and pathological features of ulcerative colitis (UC) and Crohn's disease (CD) are well known for most radiologists and gastroenterologists but on double-contrast enema, polypoid and pseudopolypoid manifestations of inflammatory bowel disease (IBD) often remain a source of major confusion. Inflammatory polyps project above the level of the surrounding mucosa. Pseudopolyposis is seen when extensive ulceration of the mucosa down to the submucosa results in scattered circumscribed islands of relatively normal mucosal remnants. Postinflammatory polyps reflect a non-specific healing of undermined mucosal and submucosal remnants and ulcers, and are mostly multiple. They have no malignant potential. Patients with long-standing UC and CD are at increased risk for developing colorectal carcinoma. Dysplasia is a precancerous histologic finding and is frequently seen in colitic colons at high risk for carcinoma. Dysplasia may be found in a radiographically normal appearing mucosa or it may be accompanied by a slightly raised mucosal lesion, a so-called dysplasia-associated lesion or mass (DALM lesion) and as a consequence radiographically detectable. Because differentiation of adenocarcinoma and dysplasia from inflammatory or postinflammatory polyps is sometimes difficult or impossible on double-contrast enema, endoscopy and biopsy are necessary for making a final diagnosis.

Dysplasia in ulcerative colitis: is radiography adequate for diagnosis?

PURPOSE: To determine to usefulness of barium enema examination in detecting dysplasia in patients with ulcerative colitis. MATERIALS AND METHODS: Radiographic findings of 22 areas of dysplasia in 10 patients (seven men, three women; aged 34-81 years at diagnosis) were reviewed. Serial changes in radiographic features of four areas of dysplasia in three patients were retrospectively investigated. RESULTS: Fourteen of 22 areas of dysplasia were shown on radiographs. Dysplasia in the rectum or sigmoid colon was depicted less frequently than that in other segments of the colon. Radiographic features were classified as obvious nodular protrusions (seven lesions), irregular mucosa (five lesions), or nodular protrusions with irregular mucosa (two lesions). Six of the seven areas of dysplasia shown as irregular mucosa were accompanied by minute spiculations in the margin of the colonic lumen. There was no correlation between radiologic features and histologic grade of dysplasia. CONCLUSION: Barium enema examination may be used as a complementary method of cancer surveillance with endoscopy. These methods show about two-thirds of lesions associated with dysplasia.

Radiographic appearance of mucosal dysplasia associated with ulcerative colitis.

The radiographic appearance of dysplasia, a precancerous histologic change that is frequently present in colitic colons at high risk for cancer, was analyzed. Over a 5-year period, 170 patients with long-standing ulcerative colitis participated in a cancer surveillance program at our institution. On entry, all patients underwent radiography with a double-contrast barium enema and colonoscopy with multiple random biopsies. All radiographs were reviewed retrospectively and were correlated with the colonoscopic and histologic findings. Dysplasia, ranging from mild to severe, was found in the biopsy specimens from 26 (15%) of these patients (in 59 different regions). Thirteen of the 26 patients with dysplasia had colectomies, and the specimens were available for review. Most dysplasia is not radiographically visible, as was the case in 40 (68%) of the 59 regions found histologically to have dysplasia. In the 19 regions in which dysplasia was visible radiographically, it appeared as a solitary nodule or as several separate nodules in 11 (19%) of the 59 regions or as a close grouping of multiple adjacent nodules with apposed, flattened edges in 8 (14%) of the 59 regions. The radiographic finding of a nodule or of several separate nodules was not specific because these nodules were indistinguishable from the inflammatory nodules often present in colitic colons. On the other hand, the radiographic finding of a close grouping of adjacent nodules with apposed, flattened edges was associated with dysplasia 50% of the time. This radiographic appearance was seen in five of our 26 patients who had dysplasia. Our study shows that barium examinations are useful in some patients with chronic ulcerative colitis by suggesting the presence of dysplasia and directing the endoscopist to specific locations for biopsy.

Radiologic approach to the detection of colorectal neoplasia.

Patients with early colorectal carcinoma detected by screening have a high survival rate. Most colorectal carcinomas evolve in preexisting adenomatous polyps, and the incidence of this malignant disease can be reduced by endoscopic polypectomy. Radiologic examination usually cannot differentiate between a benign polyp and a small carcinoma, which heightens the importance of their colonoscopic removal and subsequent histologic examination. The double-contrast enema has a higher degree of sensitivity for the detection of polyps, and probably also for early carcinoma, than the single-contrast enema. Because many of these lesions are asymptomatic, the double-contrast enema should be the standard radiologic examination of the colon in adults. This view has been championed by others and the technique has become more widely adopted. Its use contributes to the effort to reduce mortality from colorectal carcinoma.

[The complete colon examination (author's transl)]. / Die vollständige Colonuntersuchung

The radiologist must assume complete responsibility for the preparation and examination of the entire colon including the rectum. He must cooperate with and constantly check his findings with the colonoscopist. When one considers the increasing patient load, we cannot expect that all radiologists will be willing or able to assume the additional effort to produce Welin's precise results routinely. However, even with these examiners, the air contrast method can still fulfill the role of a precise and ultimate examination, especially in certain selected high risk groups. What Dr. Leo Rigler has said about lung cancer also applies to tumors of the colon. No matter how great or sophisticated the mental ability and our tools in differential diagnosis, it is all in vain if we do not find the lesion. Not to find the lesion is the irrevocable error.