Outcomes of cold snare piecemeal EMR for nonampullary small-bowel adenomas larger than 1 cm: a retrospective study.

BACKGROUND AND AIMS: Nonampullary small-bowel adenomas ≥10 mm are typically resected using cautery-based polypectomy, which is associated with significant adverse events. Studies have demonstrated the safety and efficacy of piecemeal cold snare EMR for removing large colon polyps. Our aim was to assess the safety and efficacy of cold snare EMR for removal of large adenomas in the small bowel. METHODS: A retrospective study of patients who underwent lift and piecemeal cold snare EMR of small-bowel adenomas ≥1 cm between January 2014 and March 2019 was conducted at a tertiary care medical center. Polyp characteristics at the time of index and surveillance endoscopy were collected. Primary outcomes were residual or recurrent adenoma (RRA) seen on surveillance endoscopy, polyp eradication rate, and number of endoscopic procedures required for eradication. Adverse events including immediate and delayed bleeding, perforation, stricture, pancreatitis, and postpolypectomy syndrome were assessed. RESULTS: Of 43 patients who underwent piecemeal cold snare EMR, 39 had follow-up endoscopy. Polyps ranged in size from 10 to 70 mm (mean, 26.5 mm). RRA was found in 18 patients (46%), with increased polyp size correlating with higher recurrence (P < .001). Polyp eradication was observed in 35 patients (89%), requiring a median of 2 (range, 1-6) endoscopic procedures. Only 1 patient (2.3%) had immediate postprocedural bleeding. No cases of perforation or postpolypectomy syndrome were seen. CONCLUSIONS: Piecemeal cold snare EMR may be a feasible, safe, and efficacious technique for small-bowel polyps >10 mm. Prospective, randomized studies are needed to assess how outcomes compare with traditional cautery-based polypectomy.

Arachidonic acid-derived hydroxyeicosatetraenoic acids are positively associated with colon polyps in adult males: a cross-sectional study.

Oxylipids are potent lipid mediators associated with inflammation-induced colon carcinomas and colon tumor survival. Therefore, oxylipid profiles may be useful as novel biomarkers of colon polyp presence. The aim of this study was to investigate the relationship between plasma non-esterified oxylipids and the presence of colon polyps. A total of 123 Caucasian men, ages 48 to 65, were categorized into three groups: those with no polyps, those with one or more hyperplastic polyps, and those with one or more adenomas. Plasma non-esterified oxylipids were analyzed using solid phase extraction and quantified using a targeted HPLC tandem mass spectrometric analysis. Statistical analyses included Kruskal-Wallis one-way ANOVA with Dunn's test for multiple comparison and generalized linear models to adjust for confounding factors such as age, anthropometrics, and smoking status. In general, monohydroxy omega-6-derived oxylipids were significantly increased in those with polyps. Concentrations of 5-hydroxyeicosatetraenoic acid (HETE) and 11-HETE were significantly higher in those with hyperplastic polyps and adenomas compared to those with no polyps. Arachidonic acid-derived HETEs were significantly associated with colon polyp types, even after adjusting for age, smoking, and body mass index or waist circumference in regression models. Since many of these oxylipids are formed through oxygenation by lipoxygenases (i.e., 5-, 12-, and 15-HETE, and 15- hydroxyeicosatrienoic acid [HETrE]) or auto-oxidative reactions (i.e., 11-HETE), this may indicate that lipoxygenase activity and lipid peroxidation are increased in those with colon polyps. In addition, since oxylipids such as 5-, 12-, and 15-HETE are signaling molecules involved in inflammation regulation, these oxylipids may have important functions in inflammation-associated polyp presence. Future studies should be performed in a larger cohorts to investigate if these oxylipids are useful as potential biomarkers of colon polyps.

The iatrogenic caecal polyp: can it be avoided?

A 60-year-old farmer was admitted with symptoms and signs suggestive of appendicitis. The diagnosis was confirmed at open appendicectomy where the appendix base was ligated and inverted into the caecum with a purse-string suture. Following an uneventful recovery and discharge, a barium enema identified a 2 cm filling defect in the caecal pole. A subsequent colonoscopy revealed only a tiny sessile polyp in the caecum with histology demonstrating normal colonic mucosa. This case report discusses the rare occurrence of an inverted appendix stump mimicking caecal pathology and the rationale of post-appendicectomy colonic investigation in the elderly patient.

Low colonocyte folate is associated with uracil misincorporation and global DNA hypomethylation in human colorectum.

Low folate status is a risk factor for colon carcinogenesis; mechanisms proposed to account for this relationship include uracil misincorporation into DNA and global DNA hypomethylation. We investigated whether such biomarkers are related to folate status in isolated colonocytes from colonoscopy patients. In cases with adenomatous polyps (n = 40) or hyperplastic polyps (n = 16), colonocytes were isolated from biopsies from the polyp, from a site adjacent to the polyp, and from normal mucosa 10-15 cm distal to the polyp. In polyp-free controls (n = 53), biopsies were taken from ascending, transverse, and descending areas of colon. Within adenoma cases, there was a trend (P-trend < 0.001) of decreasing colonocyte folate (pg/105 cells, mean ± CI) from the site distal to the polyp (16.9 ± 2.4), to the site adjacent to the polyp (14.7 ± 2.3), to the polyp (12.8 ± 2.0). Correspondingly, there were increases in uracil misincorporation (P-trend < 0.001) and global DNA hypomethylation (P-trend = 0.012) across the 3 sites. Colonocyte folate concentrations were significantly correlated with RBC folate concentrations, but only in individuals with generally lower (≤484 µg/L) RBC folate status (r = 0.54; P = 0.006; n = 24), and were also significantly lower in normal mucosa of cases with adenomatous polyps than in controls matched for colonic segment. In conclusion, localized folate deficiency in specific areas of colon might create carcinogenic fields and affect the development of colorectal polyps through uracil misincorporation and DNA hypomethylation; alternatively, the polyp itself might deplete folate in the surrounding tissue. Folate supplementation trials aimed at colon cancer prevention should target individuals with suboptimal folate status.

Circulating 25-hydroxyvitamin-D and risk of colorectal adenomas and hyperplastic polyps.

Colorectal adenomas are clear precursors of cancer; hyperplastic polyps may also have malignant potential. An inverse association between circulating vitamin D metabolites and adenoma risk has been reported, but less is known about vitamin D and hyperplastic polyps. We conducted a case-control study of adenomas and hyperplastic polyps among 459 members of an integrated health plan evaluated via colonoscopy. Questionnaires provided information on colorectal polyp risk factors, and plasma samples were assayed for 25-hydroxyvitamin-D [25(OH)D]. Polytomous regression was used to estimate odds ratios for adenomas (n = 149) and hyperplastic polyps (n = 85) compared to polyp-free controls (n = 225) by tertile of 25(OH)D. An inverse association between 25(OH)D and adenomas was suggested after adjustment for potential confounding factors [comparing upper to lower tertiles, OR (95%CI): 0.71 (0.38-1.30)]. After restriction of the analyses to study participants with no history of polyps, this OR estimate was reduced further [adjusted OR (95%CI): 0.52 (0.23-1.20)]. In comparison, no inverse association between hyperplastic polyps and 25(OH)D was observed among the full study participants [adjusted OR (95%CI): 1.17 (0.55-2.51)] or among those without prior polyps [adjusted OR (95%CI): 1.42 (0.55-3.65)]. Our study suggests that the established inverse association between circulating 25(OH)D and adenoma may not apply to hyperplastic polyps.

Lifestyle-related factors and colorectal polyps: preliminary results from a Norwegian follow-up and intervention study.

Lifestyle-related variables are suggested to play a major role in the development of colorectal cancer (CRC). Within a 3-year follow-up and intervention study with calcium and antioxidants against growth and recurrence of colorectal polyps, supplementary studies were performed in which different aspects of lifestyle were examined. Instead of polypectomy at diagnosis, polyps <9 mm were left in situ in 116 polyp patients (50-76 years, 50% men). After 3 years, all polyps were removed and subjected to histology. Two different sets of control groups were included (all controls were age- and sex-matched and proven to be free of polyps). We applied two different methods in order to assess most exposure variables. Generally, in case-control studies, the validity of the study outcomes is high if they are similar regardless of choice of controls and methods, since bias due to these choices may affect the risk estimates. In contrast, the validity of the study outcomes is low if dependent upon these choices. Our preliminary data support the theory that different factors may be of importance in different stages of the neoplastive formation, and that lifestyle-related factors are likely to play a major role in CRC development.

Neoplasia after ureterosigmoidostomy.

PURPOSE: The occurrence of neoplasia after ureterosigmoidostomy is well-documented in the literature. Because of its rarity, few general surgeons will gain significant exposure to this entity, and colorectal surgeons are likely to be involved with the care of these patients. The purpose of this article is to apprise colorectal surgeons about the management of neoplasia after ureterosigmoidostomy and to familiarize them with the unique anatomy of the reconstructed pelvis. METHODS: We performed a MEDLINE search to identify articles on ureterosigmoid tumors. The theories regarding the cause and pathology of these tumors were critically analyzed. A consensus was developed for screening patients with ureterosigmoidostomy and for treatment of neoplasia. RESULTS: The incidence of carcinoma after ureterosigmoidostomy ranges from 2 to 15 percent. Polyps are more common, and it seems that these tumors also follow the sequence of adenocarcinoma that is seen in the common variety of colorectal neoplasia. Neoplastic changes begin with the interaction of urine and feces and the healing colonic mucosa. Both production of nitrosamines by the action of bacteria on urine and DNA damage caused by reactive oxygen radicals produced by neutrophils at the healing anastomosis have been implicated in the pathogenesis of neoplasia. The latent period between formation of ureterosigmoidostomy and the appearance of carcinoma is between 20 and 26 years. Obstructive urinary symptoms that develop more than two years after ureterosigmoidostomy should be viewed with suspicion. The patient should be investigated with a CT scan and colonoscopy, and a barium enema may be required to delineate the anatomy further. If a benign tumor is encountered during colonoscopy, it may be removed by snare polypectomy. For a malignant tumor the segment of colon with ureteric implants should be excised, along with its lymphatic drainage. Bowel continuity is restored primarily, and the ureters are implanted in an ileal conduit. CONCLUSIONS: Patients with ureterosigmoidostomy should be followed closely for the rest of their lives. The aim of screening is to identify and treat neoplasia before malignancy develops. Furthermore, early detection of neoplasia by close screening will improve survival. Although urine cytology and occult blood are inexpensive tests, colonoscopy remains the criterion standard for follow-up of these patients. Annual colonoscopic surveillance should be started soon after the ureterosigmoidostomy but not later than five to six years after the procedure. Patients who are noncompliant with the vigorous follow-up schedule should be offered the option of resection of the colonic segment at risk with urinary diversion.

Serum selenium and colonic neoplastic risk.

BACKGROUND: Selenium deficiency has been associated with cancer risk in several organs. This association was investigated in neoplasia of the colorectum. DESIGN: A case-control study is reported with two patient series, colorectal cancer and colorectal adenomatous polyps, and a control group found to be free of colorectal neoplasia. Diagnosis was determined by colonoscopy and histologic review of suspected neoplasms. Serum drawn at the time of colonoscopy was subsequently assayed for selenium content, and quartiles based on selenium were defined. Crude and adjusted odds ratios with 95 percent confidence intervals for adenoma related to selenium were calculated, controlling for known or suspected risk factors including gender, age, race, body mass index, family history, tobacco use, alcohol consumption, serum beta carotene, serum alpha tocopherol, and serum ferritin. RESULTS: There were 138 controls who had no neoplastic disease, 139 adenoma patients, and 25 cancer patients. For adenoma, comparing higher quartiles of selenium to the first (lowest selenium), the adjusted odds ratio for the second quartile was 1.7 (95 percent confidence interval, 0.8-3.7), the third quartile was 1.4 (0.7-3.2), and the fourth (highest selenium) quartile was 1.8 (0.9-4). The odds ratios for cancer patients were 0.8 for the second quartile, 1 for the third quartile, and 1.7 for the fourth quartile. CONCLUSION: No trend could be detected toward a protective effect of higher levels of serum selenium for colonic benign or malignant tumors.

Increased prevalence of colonic adenomas in patients with acromegaly.

Forty-nine acromegalics and 57 controls matched for age and sex underwent colonoscopy. The control group consisted of patients investigated because of atypical abdominal complaints compatible with irritable bowel syndrome or constipation. The exclusion criteria for both groups included: age over 75 years, previous colonic polyps or cancer, previous colonic surgery, rectal blood loss, anemia, previous abdominal radiation, sigmoidoscopy, colonoscopy or barium enema performed for any indication within 3 years prior to the present study. Colonoscopy was successful in reaching the cecum in 72 and 77% of the controls and acromegalics, respectively (p = NS). Eleven (22%) of 49 acromegalics had biopsy-proven colonic adenomas versus only five (9%) of the control group (p < or = 0.05). Multiple adenomas were found in three of the 11 acromegalics and in none of the controls. In five of these 11 patients and in only one of the controls, at least one adenoma was located in the right colon. In addition, acromegalics tended to have larger adenomas. The group of acromegalics with and without adenomas did not differ significantly in age or duration of active disease. In conclusion, the present study shows that acromegalic patients have an increased risk of developing colonic adenomas.

Fecal ammonia in patients with adenomatous polyps and cancer of the colon.

The correlation between high intakes of protein and high incidence of human colonic cancer is unexplained. Appreciable amounts of ammonia are generated in the large bowel through bacterial degradation of proteins and peptides, and experimental studies indicate that ammonia may select for neoplastic growth. Fecal concentrations of ammonia did not differ among 17 patients with former colonic adenomas [40.6 +/- 4.5 (SE) mM], 17 patients with former colonic cancer (51.4 +/- 3.9 mM), and 16 healthy controls (46.4 +/- 6.1 mM). By use of an in vitro fecal incubation system, possible alterations in bacterial fermentation and formation of ammonia were investigated. Fecal suspensions were incubated for 6 and 24 hours with and without addition of fermentable substrates (ispaghula husk, wheat bran, albumin, and glucose; 10 mg/ml). The in vitro production of ammonia in unsupplemented fecal homogenates from both groups of patients was comparable with the production found in homogenates from healthy controls, and the response to fermentable substrates was similar in all three groups. Addition of albumin caused a marked increase in the production of ammonia, and addition of glucose increased bacterial assimilation of ammonia considerably. These well-known characteristics of bacterial metabolism of ammonia apparently did not differ between healthy individuals and patients investigated more than three months after colonoscopic polypectomy or colonic cancer resection.

Physical activity, dietary habits and adenomatous polyps of the sigmoid colon: a study of self-defense officials in Japan.

Physical activity and dietary habits were compared between 80 men with adenomatous polyps of the sigmoid colon and 1148 men with normal colonoscopy among male retiring self-defense officials. Physical activity as expressed in terms of time spent doing strenuous activities during leisure time was inversely related to the risk of adenomatous polyps. Controlling for rank, smoking, alcohol and body mass index (BMI), odds ratios for the categories of 0, 1-59, 60-119 and greater than or equal to 120 minutes per week were 1.0, 0.88, 0.70 and 0.44, respectively (trend p = 0.015). Among a limited range of foods and beverages, the consumption of rice, green tea and instant coffee tended to be associated with a decreased risk of adenomatous polyps. Although the associations observed with dietary habits still need to be substantiated, the findings on physical activity lend further evidence to the hypothesis that physical activity may be protective in the development of colon cancer.

Selenium status and the polyp-cancer sequence: a colonoscopically controlled study.

Diminished blood selenium levels have been associated with increased risk of gastrointestinal cancers in man, while dietary selenium supplementation reduces the incidence of experimental colon cancer in rats. However, no previously published data are available concerning selenium and the evolution of colon cancer from benign neoplastic colonic polyps through localized and metastatic cancer. To assess any influence of selenium on this polyp to cancer sequence, we measured plasma and erythrocyte selenium levels in colonoscopically and histologically evaluated patients with adenomatous polyps (group I), locally resectable colon cancer (group II), metastatic colon cancer (group III), and selected colonoscopy negative controls (group IV). We found no difference in selenium levels between groups IV versus groups I or II. Likewise, within group I, no difference in selenium was present for different polyp histologies or numbers of polyps. However, selenium levels did drop progressively (p = 0.028, ANOVA) from polyp (group I) to local cancer (group II, p = NS vs group I) to metastatic cancer (group III, p less than 0.05 vs group I or group II). Parallel changes were seen in both plasma and erythrocyte levels, suggesting that these selenium abnormalities are of long duration, reflecting tissue stores, and therefore capable of influencing cancer risk. We conclude that selenium stores may not be an important factor in the de novo formation of benign neoplastic colonic polyps. Although these data suggest that selenium does not affect the polyp-cancer sequence, it is possible that a subset of patients with polyps and the lowest selenium levels are at higher risk for malignant transformation. However, these human data do not support a significant role for selenium in colon carcinogenesis.

Computed tomographic findings of giant intestinal pseudopolyposis.

The cases of 3 patients with giant intestinal pseudopolyposis are presented. Giant pseudopolyposis complicated chronic ulcerative colitis in 2 patients and granulomatous colitis in 1 patient. Each patient was evaluated with either barium or Gastrografin enema as well as with computed tomography (CT) after administration of oral contrast material. The unique manifestations of this unusual lesion as demonstrated by computed tomography are described.

Inflammatory polyposis two years after ischemic colon injury.

Inflammatory polyps occur in association with ulcerative colitis, Crohn's disease, and other inflammatory diseases of the colon. The occurrence of inflammatory polyps following ischemic colitis has not been well documented. A 49-year-old man suffered complications of hypoperfusion, including renal insufficiency, hepatic failure, shock lung, and ischemic colitis following emergent repair of an acute aortic dissection. Although the renal, hepatic, and pulmonary complications resolved, the patient continued to experience intermittent bloody diarrhea more than two years after his initial presentation. Barium enema and colonoscopy revealed numerous pedunculated polyps in the descending and sigmoid colon. Histopathology of the polyps removed by snare electrocautery showed them to be inflammatory polyps. We believe these are the sequelae of chronic ischemic colitis.

Giant and symptomatic inflammatory polyps of the colon in idiopathic inflammatory bowel disease.

Four cases of giant inflammatory polyps were found in a series of 86 consecutive colectomies for inflammatory bowel disease. Two presented a distinctive clinical syndrome of abdominal pain and chronic iron-deficiency anemia due to blood loss. Secondary ulceration of the heads of the polyps accounted for the bleeding and anemia, and the size of the polyps accounted for the abdominal pain. In both cases unusually long portions of colon were involved by the giant polyps. The third and fourth cases had rare complications--reactivation of an enterocutaneous fistula and perforation of an acquired diverticulum. These cases demonstrate that giant inflammatory polyps may produce symptoms independently of the underlying inflammatory bowel disease. In reported cases of giant inflammatory polyps, approximately two-thirds had Crohn's disease and one-third had ulcerative colitis. The transverse colon was the commonest location, pain was the commonest symptom, and the polyps were localized to a short segment of colon in the majority of cases. More than 50% of cases mimicked neoplasm on barium enema. Giant inflammatory polyps may produce a variety of distinctive signs and symptoms and deserve independent recognition.

Diet and bowel diseases--past history and future prospects.

Changes in diet from ancient times until the present are described. Previously relatively low in energy and animal products yet high in fibre-containing foods, diets are now high in energy and animal products (particularly fat), yet contain less fibre. The changing incidences of bowel disorders and diseases are described, with assessments of the role of diet. Clearly, diet is implicated as regards predisposition to constipation, appendicitis, colorectal cancer and diverticular disease; however, a meaningful dietary role in irritable bowel syndrome, ulcerative colitis and Crohn's disease is doubtful. In South Africa the rarity of bowel diseases in rural blacks compared with whites affords valuable aetiological information about some bowel diseases. The low occurrence thereof (except inflammatory bowel disease) in Indian and coloured populations is not readily explicable. While dietary changes in whites are being widely urged in order to combat degenerative diseases, the magnitude of changes made is unlikely to reduce the occurrence of bowel diseases. The progressive westernization of the diets and lifestyles of less-privileged populations is likely to be associated with increases in the incidences of these diseases.

Filiform polyposis in a child with Crohn's disease.

Filiform polyps were demonstrated radiographically in a seven year old child with granulomatous colitis. Most previous reports have been in adult subjects. These slender projections of colonic mucosa and submucosa have a characteristic radiographic appearance on barium enema. It is important to recognize the condition as being benign.