Unexpected cause of upper gastrointestinal bleeding: beyond the typical complications of gallstone disease.

An 88-year-old man presented with haematemesis with haemodynamic stability requiring transfusion of 5 units of blood. Physical examination was unremarkable. Upper endoscopy identified a fistulous opening in the proximal second part of the duodenum (D2) with an oozing bleed and blood clots. A computed tomography (CT)-angiogram revealed a 18mm cystic artery pseudoaneurysm next to a fistulous communication between the gallbladder and D2, allowing the passage of a large stone (Bouveret syndrome). The patient successfully underwent emergent arterial embolization guided by a clip endoscopically-placed near the duodenal fistulous orifice. There were no intercurrences or bleeding recurrence.

When eating becomes a real nightmare.

.We present the case of a 46-year-old female with dysphagia to solids and retrosternal pain that worsened after eating. Due to mediastinal lymphadenopathies, she underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) 3 weeks before, mentioning the complaints started afterwards. On physical examination she had fever (38.3ºC). Gastroscopy revealed three 10-20mm fistulous orifices with purulent discharge at 26-32cm from the incisors and another four partially covered by fibrin in the distal esophagus. EBUS-TBNA report was reviewed, mentioning 6 needle passes through the esophagus, due to failed endotracheal intubation, without immediate complications. A cervicothoracic CT scan identified 2 mediastinal abscesses, the largest with 9cm, communicating with the esophageal fistulas. She was admitted, underwent intravenous antibiotics and endoscopy-guided nasogastric tube placement. The histopathological analysis diagnosed Castleman's disease. There was clinical and imagological improvement during admission. After 16 days she was released. Upper endoscopy was repeated one month later showing complete closure of the fistulous orifices.

Comparison of different measuring methods in the assessment of the ISNT rule and its variants in a normal population: A cross-sectional study.

PURPOSE: The aim of this study was to compare five different neuroretinal rim (NRR) measurement methods, based on quadrants and NRR widths, in the assessment of the ISNT (inferior (I) > superior (S) > nasal (N) > temporal (T)) rule, and its variants IST (inferior (I) > superior (S) > temporal (S)) rule, IS (inferior (I) > superior (S)) rule and T (temporal is the thinnest) rule in a normal population. Factors influencing compliance with this rule and its variants were also evaluated. METHODS: Stereoscopic fundus images were analysed through a dichoptic viewing system. Two graders labelled the optic disc and cup, as well as the fovea. Custom-made software automatically determined the limits of the optic disc and cup and examined the ISNT rule and its variants using several NRR measurement methods. RESULTS: Sixty-nine subjects with normal eyes were enrolled. For the various NRR measuring methods, the percentage of eyes following the rules, that is, validity ranges were 0.0%-15.9% for the ISNT rule, 31.9%-59.4% for the IST rule, 46.4%-59.4% for the IS rule and 50.7%-100.0% for the T rule. Significant intra-measurement agreement ranges were IST (κ = 0.50-0.85), IS (κ = 0.68-1.00) and T (κ = 0.24-0.77). Only the IST and IS rules achieved significant inter-measurement agreement (κ = 0.47-1.00). After multivariate and receiver operating characteristic (ROC) curve analyses, the vertical cup position cupy (area under the ROC curve (AUROC) = 0.60-0.96; cut-off = |0.005|) was the most important predictor for virtually all NRR measurement agreements for the ISNT, IST and IS rules. The horizontal cup position (AUROC = 0.50-0.92; cut-off = -0.028 to 0.05) was the most important predictive factor for the majority of the NRR measurement agreements for the T rule. CONCLUSIONS: Only the IST and IS rules are valid for the same normal subjects. The most important factor affecting the validity of the ISNT rule and its variants was the anatomical cup position. NRR measurement agreements based on NRR quadrants exhibited larger validity and better agreement. The IST and IS rules can be combined with the alternative SIT (superior (S) > inferior (I) > temporal (T)) and SI (superior (S) > inferior (I)) rules to detect almost all normal subjects.

Foreign body impaction between diverticula: an uncommon cause of chronic abdominal pain.

A woman in her 70s with a medical history of hypertension and dyslipidemia was admitted for colonoscopy due to long-term abdominal pain. During the procedure, a sharp cylindrical foreign body was identified in the sigmoid colon, imprisoned in two diametrically opposite diverticular orifices, with purulent drainage and exuberant reactive inflammatory tissue in each diverticulum. Carefully mobilization from both diverticular orifices into the colon lumen and safety removal were performed using a rat tooth forceps, without intercurrences. The removed foreign body corresponded to a chicken bone about 3 cm in size. The plain abdominal X-ray had no evidence of pneumoperitoneum. Empirical antibiotic therapy was started with complete resolution of abdominal pain during follow-up. Most foreign bodies lodged in the colon are treated conservatively as they typically pass without intervention, however, they can cause damage to the colonic mucosa and lead to perforation or infections (namely peritonitis, peritoneal abscesses, and fistulas).

Cast the bait in human fishing: an expected esophageal foreign body.

An 82-year-old woman with a medical history of dementia was admitted to the emergency department with a line under tension by lead weights through her mouth, suspecting inadvertent swallowing of a fishhook. The chest X-ray was normal. An emergent endoscopy revealed the hook imprisoned in the middle esophagus. The sharped end of the hook was carefully detached into the esophageal lumen using a rat tooth forceps and safely removed with an esophageal overtube. The esophageal defect at the impaction site was closed with the placement of two 11-mm through-the-scope metal clips, without intercurrences. Ingestion of foreign bodies is relatively rare in adults and typically pass without intervention. Their extraction is a therapeutic challenge dependent on the type and location of the object, the time since ingestion, and the probability of associated complications, such as obstruction or perforation. Endoscopic management is the first choice in the treatment of esophageal foreign bodies as a safe, effective, and minimally invasive technique, as it allows to maintain control of the object during extraction and minimize the risk of additional damage. This case report represents a successful retrieval of an unusual foreign body specially designed in a sharped shape to be ingested by fish during fishing with an esophageal overtube avoiding surgery with significant morbidity and mortality.

Iron pill-induced gastritis: an unrecognized side effect of iron-deficiency anemia.

Iron-deficiency anemia is a prevalent condition usually treated with iron supplementation. Iron pill-induced gastritis is an under-recognized, albeit serious potential complication of iron pill ingestion in the upper gastrointestinal tract. This entity must be identified by healthcare providers who prescribe iron. The diagnosis of this unusual drug-induced disease is based on endoscopic findings and histopathological examination, because the clinical symptoms are vague and non-specific. Herein we report a case of a 79-year-old woman with iron-deficiency anemia taking oral ferrous sulfate with multiple congestive and eroded polypoid lesions. Histology showed an H. pylori-negative erosive gastritis with iron deposition, confirming the diagnosis of iron pill-induced gastritis. The aim of this report is to highlight that iron pill-induced gastritis is an under-diagnosed entity that must be kept in mind when patients undergo chronic iron-pill therapy because it can lead to serious complications of the upper gastrointestinal tract.

Successful Endoscopic Closure of Esophageal Perforation in Boerhaave Syndrome Using the Over-the-Scope Clip.

Boerhaave syndrome (BS) is a rare but potentially fatal condition. Although surgery is considered the standard treatment, endoscopic therapy has acquired an important role as a minimally invasive management approach. The authors describe 2 cases of middle-aged male patients, presenting with spontaneous esophageal perforation after severe straining and vomiting. In the first case, the patient presented with a bone impaction in the upper esophagus successfully removed by rigid esophagoscopy. After the procedure, a chest X-ray/cervicothoracic computerized tomography scan (CT) showed a left hydropneumothorax and pneumomediastinum with oral contrast leak at the lower esophagus. In the second case, the patient presented to the Emergency Department with severe chest pain after an episode of vomiting. The CT showed a massive pneumomediastinum, subcutaneous emphysema, and an oral contrast leak compatible with BS. The patient was initially submitted to surgical suture, but contrast extravasation persisted after 12 days. After multidisciplinary team discussion of both patients, an upper gastrointestinal endoscopy was performed, which revealed pericentimetric wall defects at the distal esophagus. These were successfully closed using an over-the-scope clip (OTSC). After at least a 9-month follow-up, patients have remained clinically well with no relapse. The authors highlight the severity of these clinical cases and the endoscopic option that proved to be decisive in addressing BS. The favorable outcomes suggest a role for the OTSC approach in closing spontaneous esophageal perforation both as first-line and as rescue therapy after a surgical failure.

A síndrome de Boerhaave (SB) é uma entidade rara, mas potencialmente fatal. Embora a cirurgia seja o tratamento padrão, o tratamento endoscópico tem adquirido um papel importante como opção minimamente invasiva. Os autores descrevem dois casos de doentes do sexo masculino de meia-idade, que apresentaram perfuração esofágica espontânea após esforço emético intenso e vómitos. No primeiro caso, o doente apresentou impactação de um osso no esófago superior, que foi removido com sucesso por esofagoscopia rígida. Após o procedimento, o doente realizou radiografia de tórax e tomografia computorizada (TC) cervico-torácica que evidenciou hidropneumotórax esquerdo e pneumomediastino com extravasamento de contraste oral ao nível do esófago inferior. No segundo caso, o doente apresentou-se no Serviço de Urgência com toracalgia intensa após episódio de vómito. A TC mostrou pneumomediastino exuberante, com enfisema subcutâneo e extravasamento de contraste oral compatível com SB. O doente foi inicialmente submetido a rafia cirúrgica, mas o esofagograma ao 12º dia mostrou persistência de extravasamento do contraste. Após discussão em reunião multidisciplinar, ambos os doentes realizaram endoscopia digestiva alta, com visualização de orifícios pericentimétricos no esófago distal, encerrados com sucesso com a aplicação de clip overthe- scope (OTSC). Após seguimento de pelo menos 9 meses, os doentes permaneceram clinicamente bem, sem evidência de recidiva. Os autores destacam a gravidade desses casos clínicos, bem como a opção endoscópica que se mostrou decisiva no tratamento da SB. Os resultados favoráveis sugerem um papel para a abordagem com OTSC no tratamento da perfuração esofágica espontânea, tanto como tratamento de primeira linha, como terapêutica de resgate após falência do tratamento cirúrgico.

Duodenal variceal bleeding as a presentation of hepatocellular carcinoma

A 79-year-old man with alcoholic liver cirrhosis without regular medical follow-up, presented at the emergency room with hematemesis. An upper endoscopy revealed a varix at the anterior wall of bulb with a red wale sign, indicating recent bleeding. An injection N-butyl-2 cyanoacrylate plus metacryloxisulfolane was successfully performed. The abdominal computed tomography angiography scan revealed a 29x26-mm nodule consistent with hepatocellular carcinoma (HCC), tumoral portal vein thrombosis (and communicating collateral from the superior mesenteric vein feeding the duodenal varix with no splenorenal shunt. After endoscopic therapy, the patient remained asymptomatic without rebleeding. Given HCC stage D (Barcelona Clinic Liver Cancer), after multidisciplinary discussion, the patient was evaluated for best supportive care. Ectopic varices are clinically challenging causes of portal hypertensive bleeding associated with significant mortality, requiring a high index of suspicion and multimodal diagnostic and therapeutic approaches. The management includes endoscopic therapy, interventional radiology techniques (TIPS with variceal embolization, balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration) or surgery. The best endoscopic treatment modality remains unclear because there are no studies directly comparing the different endoscopic techniques. In setting of ectopic varices, abdominal imaging is mandatory to exclude splanchnic vein thrombosis, HCC and to map portosystemic collaterals to guide further treatments. (AU)

Lymphogranuloma Venereum-Associated Proctitis Mimicking a Malignant Rectal Neoplasia: Searching for Diagnosis.

Background: Chlamydia trachomatis-lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) and an uncommon cause of proctitis. The diagnosis requires a high index of clinical suspicion, since the clinical, imaging, endoscopic, and histological findings can mimic multiple benign or malignant conditions like inflammatory bowel disease and rectal neoplasms. Case Presentation: We present the case of a 48-year-old Caucasian male with no significant previous medical history who was admitted due to the suspicion of a rectal neoplasia. He underwent an abdominopelvic computed tomography (CT) scan and pelvic magnetic resonance imaging (MRI) before admission due to complaints of anorectal pain, hematochezia, and constipation over the previous 2 weeks. The examination revealed a circumferential rectal wall thickening, infiltration of the perirectal fat and invasion of the mesorectal fascia, associated with perirectal fat lymphadenopathy. A radiological diagnosis of a rectal malignant neoplasia staged as T4N2MX was stated. Digital rectal examination identified a circumferential rectal tumor. Rectosigmoidoscopy showed an extensive and circumferential ulceration of the rectal mucosa, with elevated geographical borders, exudate, and aphthoid erosions at the proximal limit of the endoscopic mucosal ulceration. Biopsy specimens revealed acute ulcerative proctitis with lymphoplasmocytic inflammatory infiltrate but no evidence of dysplasia or malignancy. A STI screening was positive for HIV-1 (CD4+ 251/mm3; N = 700-1,100) and C. trachomatis, with an elevated IgA-specific antibody titer (52.000; N < 5.0), suggesting LGV disease. The diagnosis was confirmed by the identification of C. trachomatis DNA on rectal swab. Other infectious causes of acute proctitis were excluded. When faced with these results, the patient ended up mentioning that he had unprotected anal sex with men. He started treatment with doxycycline 100 mg twice a day for 21 days, with a drastic improvement. Rectosigmoidoscopy was repeated and showed clear signs of progressive resolution of the ulcerative proctitis. Discussion: LGV-associated proctitis, often undervalued, is a reemerging disease which should always be considered a benign cause of rectal mass, in order to avoid delay in diagnosis and development of complications. Diagnosis becomes more challenging in patients with unknown HIV status. A detailed clinical history, including sexual behaviors, is a vital step to achieve the final diagnosis.

Introdução: A infeção por Chlamydia trachomatis-linfogranuloma venéreo (LGV) é uma doença sexualmente transmissível (DST), sendo uma causa incomum de proctite. O diagnóstico exige um elevado grau de suspeição, dado que os achados clínicos, radiológicos, endoscópicos e histológicos podem mimetizar múltiplas condições benignas ou malignas, como a doença inflamatória intestinal e as neoplasias retais. Caso clínico: Apresentamos o caso de um homem de 48 anos, caucasiano, sem antecedentes relevantes, admitido por suspeita de neoplasia retal. Por queixas de dor anorretal, hematoquézias e obstipação com 2 semanas de evolução, realizou uma tomografia computadorizada abdominopélvica e uma ressonância magnética pélvica, que revelaram espessamento retal circunferencial, infiltração da gordura periretal e invasão da fáscia mesoretal, associados a linfadenopatias locais, sugestivos de malignidade retal (T4N2MX). O toque retal identificou uma tumoração retal circunferencial.A retosigmoidoscopia mostrou mucosa retal com ulceração extensa e circunferencial, bordos geográficos elevados, exsudado e erosões aftóides no limite proximal da ulceração mucosa. As biópsias revelaram proctite ulcerada aguda com infiltrado linfoplasmocitário difuso, sem displasia ou neoplasia. O screening de DST foi positivo para VIH-1 (CD4+ 251/mm3; N: 700­1100) e título elevado de IgA para C. trachomatis (52 000; N< 5), sugerindo LGV. O diagnóstico foi confirmado pela identificação do DNA de C. trachomatis em zaragatoa retal. Outras causas infecciosas de proctite aguda foram excluídas. Perante estes resultados, o doente acabou por mencionar que tinha tido relações homossexuais anais desprotegidas. Iniciou doxiciclina (100 mg duas vezes por dia, por 21 dias) com melhoria sintomática drástica. Repetiu retosigmoidoscopia, com sinais de proctite ulcerada em resolução. Discussão: A proctite por LGV, frequentemente desvalorizada, é uma doença re-emergente, que deve ser sempre equacionada como causa benigna de massa retal, de modo a evitar o atraso diagnóstico e o desenvolvimento de complicações. O diagnóstico torna-se mais desafiante em doentes com status VIH desconhecido. A história clínica detalhada, incluindo comportamentos sexuais de risco, é fundamental para o diagnóstico.

Role of Intestinal Ultrasound in the Evaluation of Postsurgical Recurrence in Crohn's Disease: Correlation with Endoscopic Findings.

Introduction: Endoscopy remains the exam of choice in the evaluation of activity in Crohn's disease (CD) after surgery (ACD-AS). However, intestinal ultrasound (IUS) may represent a noninvasive alternative. The objective of this study is to determine the diagnostic accuracy of this modality compared to endoscopy. Material and Methods: This is a cross-sectional study, comprising a period of 14 months, carried out in patients with established CD and ileocecal resection due to the disease. IUS (HI-VISION Avius®, Tokyo, Japan) was performed with linear probe B-mode/Doppler prior to ileocolonoscopy. IUS and ileocolonoscopy were performed on the same day by 2 specialists in Gastroenterology dedicated to ultrasound and inflammatory bowel disease, in a double-blind mode. Collected demographic and clinical data (Harvey-Bradshaw Index [HBI]; remission ≤4), serological/fecal inflammatory parameters (leukocytes [4-10 × 109 cells/L], C-reactive protein [≤0.5 mg/dL], and fecal calprotectin [<50 mg/kg]), endoscopy (Rutgeerts score: remission 3 mm and/or Limberg score >1) was abnormal in 61.5% (n = 24) of the cases. Endoscopic remission (Rutgeerts score

Introdução: A endoscopia permanece o exame de eleição na avaliação da atividade da Doença de Crohn (DC) póscirurgia (ADC-PC). No entanto, a ecografia dirigida à parede digestiva (Eco-PD) pode representar uma alternativa não-invasiva. O objetivo do trabalho é determinar a acurácia diagnóstica e concordância desta modalidade comparativamente à endoscopia. Materiais e métodos: Estudo transversal, compreendendo um período de 14 meses, efetuado a doentes com DC estabelecida e resseção ileocecal pela doença. Realizada Eco-PD (HI-VISION Avius®, Tokyo, Japan) com sonda linear em modo-B/Doppler previamente à ileocolonoscopia. A Eco-PD e ileocolonoscopia foram realizadas no mesmo dia por 2 especialistas dedicados a ecografia e doença inflamatória intestinal, de forma duplamente cega. Recolhidos dados demográficos, clínicos (índice Harvey-Bradshaw [HBI; remissão: ≤4]), parâmetros inflamatórios serológicos/fecais (leucócitos [4 < N < 10 × 109 células/L], proteína C reativa [≤0,5 mg/dL], calprotectina fecal [N <50 mg/kg]), endoscópicos (score Rutgeerts: remissão < i2) e ecográficos (espessamento [N ≤ 3mm] e vascularização da parede digestiva pelo score semi-quantitativo de Limberg [ausente = 0; escassa = 1; moderada = 2; marcada = 3]). Resultados: Incluídos 39 doentes (sexo feminino: 64,1%, idade média: 43,5 ± 15,3 anos). Seguimento mediano pós-cirurgia de 9 anos (IQR 9). Classificação Montreal: L1 61,5% (n = 24), L3 38,5% (n = 15), B1 e B2 28,2% (n = 11) e B3 43,6% (n = 17).A maioria estava em remissão clínica (87,2%; n = 34) com HBI médio de 2,1 ± 2,2. Vinte e dois doentes (56,4%) tinham marcadores inflamatórios dentro de parâmetros normais. A Eco-PD (espessamento parede intestinal >3 mm e/ou Limberg >1) foi anormal em 61,5% (n = 24). Remissão endoscópica (Rutgeerts < i2) em 53,8% (n = 21). Comparativamente à endoscopia, a Eco-PD (AUROC 0,75; p = 0,007) mostrou acuidade diagnóstica superior aos parâmetros inflamatórios (AUROC 0,66; p = 0,083) e clínica (AUROC 0,64; p = 0,139). A ecografia mostrou uma moderada concordância com a endoscopia (ĸ = 0,5; p = 0,001), superior aos parâmetros inflamatórios (ĸ = 0,33, p = 0,041) ou clínica (ĸ = 0,29, p = 0,01). Conclusões: A avaliação ecográfica da parede digestiva é uma técnica não invasiva que mostrou uma boa acuidade diagnóstica e uma concordância moderada com a endoscopia, superior à clínica e parâmetros inflamatórios serológicos/fecais.

Duodenal variceal bleeding as a presentation of hepatocellular carcinoma.

A 79-year-old man with alcoholic liver cirrhosis without regular medical follow-up, presented at the emergency room with hematemesis. An upper endoscopy revealed a varix at the anterior wall of bulb with a red wale sign, indicating recent bleeding. An injection N-butyl-2 cyanoacrylate plus metacryloxisulfolane was successfully performed. The abdominal computed tomography angiography scan revealed a 29x26-mm nodule consistent with hepatocellular carcinoma (HCC), tumoral portal vein thrombosis (and communicating collateral from the superior mesenteric vein feeding the duodenal varix with no splenorenal shunt. After endoscopic therapy, the patient remained asymptomatic without rebleeding. Given HCC stage D (Barcelona Clinic Liver Cancer), after multidisciplinary discussion, the patient was evaluated for best supportive care. Ectopic varices are clinically challenging causes of portal hypertensive bleeding associated with significant mortality, requiring a high index of suspicion and multimodal diagnostic and therapeutic approaches. The management includes endoscopic therapy, interventional radiology techniques (TIPS with variceal embolization, balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration) or surgery. The best endoscopic treatment modality remains unclear because there are no studies directly comparing the different endoscopic techniques. In setting of ectopic varices, abdominal imaging is mandatory to exclude splanchnic vein thrombosis, HCC and to map portosystemic collaterals to guide further treatments.

Hemobilia due to porto-biliary fistula complicating endoscopic retrograde cholangiopancreatography after a recent liver transplantation.

A 60-year-old woman with autoimmune hepatitis submitted to liver transplantation presented with a biliary anastomotic stenosis. An endoscopic retrograde cholangiopancreatography (ERCP) was complicated with a porto-biliary fistula due to the misplacement of a biliary stent. After multidisciplinary discussion, and the stent was endoscopically removed while a percutaneous transhepatic fully-covered self-expanded metal stent was placed in portal vein. Iatrogenic porto-biliary fistula following biliary stent placement is a rare and potentially life-threatening ERCP complication. In a suspected stent-related portal vein injury, this multidisciplinary strategy combining gastroenterology and radiology proved to be an effective and safe minimally invasive technique avoiding catastrophic consequences.

An Atypical Presentation of a Colonic Lipoma: Avoiding Surgery with a Deeper Endoscopic Look.

INTRODUCTION: Colonic lipomas are common mesenchymal tumours. They are usually asymptomatic and incidentally diagnosed during endoscopic or radiological examinations. Taking into account their typical endoscopic and radiological features and benign nature, tissue sampling, resection or follow-up are generally not required. CASE REPORT: A 61-year-old woman with poor surgical fitness presented with colonic subocclusion and lower gastrointestinal bleeding. A colonoscopy performed 1 month earlier showed a large polypoid lesion with necrotic and ulcerated areas occupying the lumen of the proximal ascending colon with inconclusive histology. An abdominopelvic computed tomography scan with intravenous contrast was done revealing a cecal-colonic intussusception of a heterogeneous mass. The patient was successfully managed conservatively. A delayed revision colonoscopy showed a significantly smaller atypical subepithelial lesion with no necrosis or ulceration. A single, large and deep incision with a pre-cut needle-knife® allowed the direct collection of lesion tissue using standard biopsy forceps through the so-called single-incision needle-knife® (SINK) biopsy technique. Histological examination was compatible with submucosal lipoma. After 18 months of follow-up, the patient remains asymptomatic. DISCUSSION/CONCLUSION: Colonic lipoma complications are rare and can lead to misdiagnosis; in general, they are surgically managed. A conservative approach and a minimally invasive endoscopic procedure allowed a definite diagnosis avoiding the morbidity and mortality of a major surgical intervention in a high-risk patient.

INTRODUÇÃO: Os lipomas do cólon são tumores mesenquimatosos comuns. Frequentemente são assintomáticos e diagnosticados, incidentalmente, em exames endoscópicos e imagiológicos. O diagnóstico histológico, resseção e vigilância não costumam ser necessários devido aos achados endoscópicos e imagiológicos típicos e à sua natureza benigna. CASO CLÍNICO: Uma mulher de 61 anos com contraindicação relativa para cirurgia abdominal recorreu ao serviço de urgência por quadro clínico de suboclusão intestinal e hemorragia digestiva baixa. A colonoscopia, realizada um mês antes, demonstrava uma lesão polipoide com área de necrose e ulceração a ocupar o lúmen do cólon ascendente proximal, com estudo histológico inconclusivo. Foi efetuada uma tomografia computorizada abdominopélvica com contraste intravenoso que revelou uma invaginação ceco-cólica de uma massa heterogénea.Optou-se por uma abordagem conservadora com remissão clínica. A colonoscopia de revisão diferida mostrou, na mesma localização, uma lesão subepitelial de menores dimensões, atípica, sem ulceração ou necrose. Com uma faca-agulha de pré-corte foi efetuada uma incisão única e profunda que permitiu a colheita direta de material usando uma pinça de biopsias standard através da técnica denominada biopsia por faca-agulha de précorte de incisão única. A análise histológica foi compatível com lipoma submucoso. Cerca de 18 meses após o episódio a doente permanece assintomática. DISCUSSÃO/CONCLUSÃO: As complicações do lipoma do cólon são raras e podem levar a um diagnóstico erróneo, geralmente tratado cirurgicamente. Uma abordagem conservadora inicial e um procedimento endoscópico minimamente invasivo permitiram o diagnóstico definitivo, evitando a morbilidade e mortalidade associadas a uma intervenção cirúrgica major numa doente de alto risco.