Improving sessile serrated adenoma detection rates with high definition colonoscopy: A retrospective study.

BACKGROUND: Sessile serrated adenomas (SSAs) are important premalignant lesions that are difficult to detect during colonoscopy due to poor definition, concealment by mucous caps, and flat appearance. High definition (HD) colonoscopy may uniquely aid in the detection of these inconspicuous lesions compared to standard definition (SD) colonoscopes. In the absence of existing clinical guidelines to obligate the use of HD colonoscopy for colorectal cancer screening in average-risk patients, demonstrating the benefit of HD colonoscopy on SSA detection rate (SSADR) may help strengthen the evidence to recommend its use in all settings. AIM: To evaluate the benefit of HD colonoscopy compared to SD colonoscopy on SSADR in average-risk patients undergoing screening colonoscopy. METHODS: Data from screening colonoscopies for patients aged 50-76 years two years before and two years after the transition from SD colonoscopy to HD colonoscopy at our large, academic teaching center were collected. Patients with symptoms of colorectal disease, positive occult blood test, history of colon polyps, cancer, polyposis syndrome, inflammatory bowel disease or family history of colon cancer or polyps were excluded. Patients whose endoscopists did not perform colonoscopies both before and after scope definition change were also excluded. Differences in individual endoscopist SSADR, average SSADR, and overall SSADR with SD colonoscopy vs HD colonoscopy were also evaluated for significance. RESULTS: A total of 3657 colonoscopies met eligibility criteria with 2012 colonoscopies from the SD colonoscopy period and 1645 colonoscopies from the HD colonoscopy period from a pool of 11 endoscopists. Statistically significant improvements of 2.30% in mean SSADR and 2.53% in overall SSADR were noted with HD colonoscopy (P = 0.00028 and P = 0.00849, respectively). On the individual level, three endoscopists experienced statistically significant benefit with HD colonoscopy (+5.74%, P = 0.0056; +4.50%, P = 0.0278; +4.84%, P = 0.03486). CONCLUSION: Our study suggests that HD colonoscopy statistically significantly improves sessile serrated adenoma detection rate in the screening of average risk patients during screening colonoscopy. By improving the detection and removal of these lesions, adoption of HD colonoscopy may reduce the significant premalignant burden of sessile serrated adenomas.

Significant Variation in the Detection Rates of Proximal Serrated Polyps Among Academic Gastroenterologists, Community Gastroenterologists, and Colorectal Surgeons in a Single Tertiary Care Center.

INTRODUCTION: Recent studies have demonstrated that the protective effect of colonoscopy against colorectal cancer is lower in the proximal colon. Proximal serrated polyps, including sessile serrated adenomas and proximal hyperplastic polyps, can be frequently missed and pose a risk of interval cancers. AIM: To investigate the overall adenoma detection rate (ADR) and the proximal serrated polyp detection rate (PSPDR) among academic gastroenterologists, community gastroenterologists, and colorectal surgeons from a single institution, all of whom have received formal training in colonoscopy during their fellowship. METHODS: All complete screening colonoscopies for patients aged 50 or older with a good to excellent bowel preparation performed by different endoscopists at Medstar Washington Hospital Center (Washington, DC) from July 2015 to December 2017 were reviewed. Pathology reports of the resected polyps were manually reviewed. RESULTS: A total of 2850 screening colonoscopies meeting the inclusion criteria were performed by 18 endoscopists (6 academic, 7 community, and 5 colorectal surgeons). There was no significant difference in the mean ADR among the three groups of endoscopists: academic gastroenterologists, community gastroenterologists, and colorectal surgeons (40.3% vs 36.0% vs 39.6%, respectively). However, academic gastroenterologists had a significantly higher PSPDR compared to community gastroenterologists or colorectal surgeons (12.3% vs 5.4% vs 4.5%, respectively, ANOVA p = 0.006). CONCLUSION: Our novel data show that academic gastroenterologists had a significantly higher PSPDR compared to community gastroenterologists or colorectal surgeons despite a comparable overall ADR among the three groups. PSPDR may be considered as an important quality indicator for colonoscopy, apart from ADR.

Role of colonoscopy in diagnosis of capecitabine associated ileitis: Two case reports.

BACKGROUND: Capecitabine is considered a first line agent in adjuvant therapy for breast and colorectal cancer. However, cases of severe diarrhea have been reported with increasing frequency in recent years. When diarrhea is severe and prolonged, capecitabine associated ileitis should be considered as a possible etiology. CASE SUMMARY: Herein, we present two cases of capecitabine ileitis, specifically involving the terminal ileum and ascending colon. We will demonstrate the disease course and treatment modalities applied to alleviate this condition, as well as discuss the merits of using colonoscopy to aid in diagnosis. CONCLUSION: Ultimately our cases demonstrate that symptomatic management with traditional anti-diarrheal medications is largely ineffective. Prompt recognition and discontinuation of capecitabine is an imperative step in proper management of this condition and colonoscopy with biopsy can be helpful when the diagnosis is unclear.

Immune checkpoint inhibitor-induced colitis: A comprehensive review.

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target down-regulators of the anti-cancer immune response: Cytotoxic T-lymphocyte antigen-4, programmed cell death protein-1, and its ligand programmed death-ligand 1. ICIs have revolutionized the treatment of a variety of malignancies. However, many immune-related adverse events have also been described which mainly occurs as the immune system becomes less suppressed, affecting various organs including the gastrointestinal tract and causing diarrhea and colitis. The incidence of immune-mediated colitis (IMC) ranges from 1%-25% depending on the type of ICI and if used in combination. Endoscopically and histologically there is a significant overlap between IMC and inflammatory bowel disease, however more neutrophilic inflammation without chronic inflammation is usually present in IMC. Corticosteroids are recommended for grade 2 or more severe colitis while holding the immunotherapy. About one third to two thirds of patients are steroid refractory and benefit from infliximab. Recently vedolizumab has been found to be efficacious in steroid and infliximab refractory cases. While in grade 4 colitis, the immunotherapy is permanently discontinued, the decision is controversial in grade 3 colitis.

Hepatotoxicity induced by immune checkpoint inhibitors: a comprehensive review including current and alternative management strategies.

INTRODUCTION: Immune checkpoint inhibitors (ICIs) block cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1)/PD ligand 1 (PD-L1) receptors that control antitumor activities of lymphocytes. While highly efficacious, these drugs have been associated with several immune-related adverse events (irAEs) due to the disruption of self-tolerance. Immune-mediated hepatitis (IMH) usually presents as mild elevations of liver enzymes though it can rarely be associated with life-threatening hepatic injury. Areas covered: A comprehensive review was performed to define the clinicopathologic forms of liver injury associated with ICIs, comparing the various ICI classes as well as comparing this form of IMH with idiopathic autoimmune hepatitis and drug-induced autoimmune hepatitis. Liver biopsy has proven very useful in selected patients. A specific form of fibrin ring granulomatous hepatitis appears to be associated with IMH. The current societal treatment algorithms and emerging data were reviewed to determine when to utilize corticosteroids. Expert opinion: Monitoring for severe ICI-IMH is recommended although acute liver failure remains rare. Most patients with grade 3-4 hepatotoxicity respond to corticosteroids, but a subset of patients with mild hepatitis on liver biopsy resolve without steroids and need to be carefully selected in concert with the consultation of a hepatologist.

Biliary Obstruction due to a Pancreatic Plasmacytoma.

Obstructive jaundice, weight loss, and anorexia often raise a concern for pancreatic malignancy. Although pancreatic adenocarcinoma is the most common form of pancreatic cancer, not all pancreatic malignancies are exocrine in origin. With advancement in endoscopic ultrasound with fine needle aspiration, it has become easier to make correct diagnosis. Plasmacytoma of pancreas is a solitary tumor of plasma cells and it can also lead to the same clinical presentations. Immunohistochemistry is required to make the diagnosis of plasmacytoma. However, when there are other systemic manifestations, such as hypercalcemia, renal injury, and anemia, a diagnosis of multiple myeloma should be suspected and confirmed by cytology or biopsy. It is very important to differentiate plasmacytoma from multiple myeloma as the management for each is different. Herein, we describe a case of multiple myeloma presenting as a pancreatic plasmacytoma causing obstructive jaundice.

A case report of symptomatic presacral myelolipoma.

RATIONALE: Extra-adrenal myelolipoma in the presacral area often raises a concern for liposarcoma because they have similar radiologic features. PATIENT CONCERNS: A 70-year-old woman with multiple abdominal surgeries in the past presented with persistent lower abdominal pain and anemia. A presacral mass, found on a pelvic magnetic resonance image (MRI), was suspicious of liposarcoma, as it is the most common fat containing mass in the presacral area. It is often difficult to make a diagnosis of myelolipoma just based on the radiological studies, which necessitates a histopathologic examination of the resected mass for a definitive diagnosis. DIAGNOSES: Myelolipoma is an encapsulated, benign tumor containing mature adipocytes and hematologic cells. Most of the patients with myelolipoma remain asymptomatic but continued growth of tumor without local invasion can lead to compression of nearby structures, causing persistent pain. INTERVENTIONS: Asymptomatic patients do not require intervention but surgical resection is indicated for persistent pain or hemorrhage inside the tumor. Our patient had 2 indications for surgery - persistent pain as well as a provisional diagnosis of liposarcoma. After the surgical resection, pelvic pain was resolved, and a diagnosis of myelolipoma was made based on histopathologic examination. OUTCOMES: Patient was reassured that it was myelolipoma, a benign tumor, not requiring subsequent surveillance for recurrence. LESSONS: Despite advancement in imaging techniques, and knowledge of the radiological features of myelolipoma, it still remains as a challenge for clinicians to make the distinction between liposarcoma and myelolipoma only based on diagnostic radiology. Although myelolipoma is a benign tumor, if patient suffers from persistent pain due to local mass effect, surgical resection is required.

Monitoring inflammatory bowel disease during pregnancy: Current literature and future challenges.

Inflammatory bowel disease has a high prevalence in women of childbearing age and can have a significant impact on pregnancy, from conceiving to carrying the pregnancy. Active disease during pregnancy is known to have negative effects on pregnancy outcomes; therefore, careful monitoring during this period is an important but challenging aspect of care and is crucial as it affects important management decisions. Recent data seems to suggest that endoscopy is a relatively safe procedure during all trimesters of pregnancy. Serum biomarkers such as C-reactive protein and fecal calprotectin are helpful non-invasive markers, but have shown conflicting results for correlation with disease activity in some initial studies. Further work is necessary to establish standard of care monitoring during pregnancy.

Association between common variable immunodeficiency and collagenous infiltrative disorders of the gastrointestinal tract: A series of four patients.

Hypogammaglobulinemia/common variable immunodeficiency (CVID) may lead to disruption of the gut mucosal immune barrier. Collagenous infiltrative disorders of the intestinal tract (colitis, gastritis, sprue) constitute a relatively new spectrum of gastrointestinal disorders. Our aims were (1) to determine the association between immunoglobulin deficiency state like CVID and collagenous infiltrative disorders of the gut and (2) to study the clinic-pathologic characteristics and treatment outcomes in these patients. A retrospective search was conducted to identify cases with concurrence of these two conditions at an academic center from 2007 to 2013. Four such patients were identified from our database: three with collagenous colitis and one with collagenous gastritis. All patients with collagenous colitis had normal colonic mucosa while the patient with collagenous gastritis had nodular gastric mucosa. Only one patient out of four had decreased plasma cells in the submucosa as expected in low immunoglobulin states. All patients had improvement in their symptoms on immunoglobulin therapy with considerable remission on budesonide. Literature search revealed reporting of four similar patients. In conclusion, (1) the association between collagenous infiltrative disorders of the gut and CVID and its prompt response to immunoglobulins with effective maintenance with budesonide are novel findings. Our study also shows that the presence of plasma cells should not rule out the possibility of CVID. (2) In patients with chronic diarrhea, hypogammaglobulinemia and collagenous colitis/sprue should be considered for the available effective treatments such as immunoglobulins and budesonide.

Spiral Enteroscopy Utilizing Capsule Location Index for Achieving High Diagnostic and Therapeutic Yield.

Background and Aim. Spiral enteroscopy (SE) is a new small bowel endoscopic technique. Our aim is to review the diagnostic and therapeutic yield, safety of SE, and the predictive role of prior capsule endoscopy (CE) at an academic center. Methods. A retrospective review of patients undergoing SE after prior CE between 2008 and 2013 was performed. Capsule location index (CLI) was defined as the fraction of total small bowel transit time when the lesion was seen on CE. Results. A total of 174 SEs were performed: antegrade (147) and retrograde (27). Abnormalities on SE were detected in 65% patients. The procedure was safe in patients with surgically altered bowel anatomy (n = 12). The diagnostic yield of antegrade SE decreased with increasing CLI range. The diagnostic yield of retrograde SE decreased on decreasing CLI range. A CLI cutoff of 0.6 was derived that determined the initial route of SE. Vascular ectasias seen on CE were detected in 83% cases on SE; p < 0.01. Conclusions. SE is safe with a high diagnostic and therapeutic yield. CLI is predictive of the success of SE and determines the best route of SE. The type of small bowel pathology targeted by SE may affect its utility and yield.

A diagnostic challenge in a young woman with intractable hiccups and vomiting: a case of neuromyelitis optica.

Intractable nausea and vomiting along with hiccups is a commonly encountered problem on any general medicine or gastroenterology service. These symptoms are usually not appreciated as the possible initial manifestation of neuromyelitis optica (NMO). Missing diagnosis at this early stage will lead to a delay in the treatment, and hence, irreversible complications including blindness and paraplegia could occur. We report a case of a 22-year-old young female who presented with intractable hiccups and vomiting. After extensive evaluation, she was found to have NMO which involved the area postrema, the vomiting center of the brain. Early diagnosis from the clinical picture aided by aquaporin-4 serologic testing is extremely important to allow early initiation of immunosuppressive therapy. Immunosuppression gives an opportunity to modify the disease at an earlier stage rather than waiting for evolution of disease to fulfill the diagnostic criteria of NMO.

Survey of anal sphincter dysfunction using anal manometry in patients with fecal incontinence: a possible guide to therapy.

BACKGROUND: Despite the surge of new medical and surgical approaches to treat fecal incontinence, the types of sphincter abnormalities in patients with incontinence have not been well characterized. We aimed to categorize anal sphincter dysfunction using anorectal manometry in patients with fecal incontinence as a potential guide for improved treatment. METHODS: A retrospective review of 162 consecutive patients with fecal incontinence referred for anorectal manometry was performed. Resting anal pressure and maximal squeeze pressure were considered as measures of internal anal sphincter and external anal sphincter function respectively. RESULTS: Mean age of the patients was 63 years (13-89); females (81.5%) and males (18.5%). 74% of the patients had sphincter dysfunction on anorectal manometry. Internal anal sphincter dysfunction was present in 62% patients vs. external anal sphincter dysfunction present in 44% patients. 80% females had abnormal manometry vs. 44% in males (P<0.0001). Internal anal sphincter dysfunction was present in 68% females vs. 37% in males (P=0.0026). CONCLUSIONS: Overall, abnormal anorectal manometry studies revealed that internal anal sphincter dysfunction is the most common finding, alone or in combination with external anal sphincter dysfunction. We suggest that anorectal manometry may be important to delineate anal sphincter function prior to using newer therapeutic mechanical devices. Future studies using pharmacological agents to increase internal anal sphincter tone may be of clinical importance. Finally, the classification of fecal incontinence based on the type of sphincter dysfunction may be an improved guide in the selection of newer agents in treating fecal incontinence.

A Challenging Diagnosis of Fluctuating Dyspnea: Myasthenia Gravis.

Isolated respiratory muscles weakness is an unusual presentation of Myasthenia Gravis (MG). We present a case of 49-year-old male with undiagnosed MG who presented with fluctuating dyspnea on exertion and at rest. There was no peripheral muscle involvement, diagnostic tests and standard electromyography was normal, and the serologic tests were negative. The repetitive nerve stimulation and Single Fiber Electromyography revealed the diagnosis of MG. Interestingly the patient did not have sufficient therapeutic response on first line agents and required immunoglobulins and corticosteroids due to respiratory muscle involvement. Since skeletal muscle weakness is a cardinal feature of MG, dyspnea may be fluctuating as in our patient causing further difficulty in diagnosis as the pulmonary function tests performed during remission may be normal. This presentation highlights the need to consider MG in the differential diagnosis of unexplained dyspnea on exertion/rest.