Endoscopy Unknowns

Gary R Lichtenstein, MD

Director, Center for IBD

University of Pennsylvania School of Medicine

Hospital of the University of PA

Philadelphia, PA

Patient Case 1 Female, age 28 yr,

with UC x 2 yrs. On maintenance mesalamine 4.8 grams x 1.5 years

New onset diarrhea x 2 months

Symptoms Suprapubic Pain Diarrhea (3-5 loose stools/day) 5-lb weight loss No Fever BRBPR- mild

Physical examination Abdomen- soft Nontender No mass

SH Lived in Louisiana x 10 yrs

and just moved to Philadelphia

No Cigs

Laboratory values WBC: 8,500 cells/µL Hgb: 10.8 g/dL CRP: 10.0 mg/dL Albumin: 3.2 g/dL Negative - stool C & S, C diff

CRP = C-reactive protein;

RLQ = right lower quadrant

C & S- culture and sensitivity

C Diff- Clostridium Difficile

Patient Case 1 Clinical Course-

Pt was given 40 mg a day of prednisone for one week with a taper and when she reached10 mg a day she flared. She is now on week 8 of therapy. She is having 3-5 BM a day.

Flex Sig - done

How Do You Report This ?

Case 1

ARS Question Case 2

Appropriate treatment options for this patient at this time includes (One single best answer):

1.) No treatment is Needed

2.) Fluconazole

3.) Prazquintel

4.) Iodoquinol

5.) Albendazole

Trichuris Trichiura: WhipwomCase 1

Endemic areas : - Worldwide distribution of Trichuris trichiura, with an estimated 1 billion human infections.

- It is chiefly tropical, especially in Asia and, to a lesser degree, in Africa and South America

- Within the United States, infection is rare overall but may be common in the rural Southeast, where 2.2 million people are thought to be infected.

Poor hygiene is associated with trichuriasis as well as the consumption of shaded moist soil, or food that may have been fecally contaminated.

Children are especially vulnerable to infection due to their high exposure risk.

Source: http://www.cdc.gov/parasites/whipworm/- accessed 12/04/2014

Trichuris Trichiura: WhipwomCase 1

Who Gets Disease: - Whipworm is a soil-transmitted helminth (STH) and is the third most common roundworm of humans.

- Whipworm causes an infection called trichuriasis and often occurs in areas where human feces is used as fertilizer or where defecation onto soil happens.

The worms are spread from person to person by fecal-oral transmission or through feces-contaminated food

Source: http://www.cdc.gov/paorm/- accessed 12/04/2014

Trichuris Trichiura: WhipwomCase 1

Presentation: - People with heavy symptoms can experience frequent, painful passage of stool that contains a mixture of mucus, water, and blood.

- Rectal prolapse can also occur.

- Children with heavy infections can become severely anemic and growth-retarded

Treatment: - Anthelminthic medications (drugs that rid the body of parasitic worms), such as albendazole and

mebendazole, are the drugs of choice for treatment. Infections are generally treated for 3 days

Source: http://www.cdc.gov/parasites/whipworm/- accessed 12/04/2014

Patient Case 2: Female, age 28 yr,

with UC x 2 yrs. On maintenance mesalamine 4.8 grams x 1.5 years

New onset diarrhea x 2 months

Symptoms Suprapubic Pain Diarrhea (3-5 loose stools/day) 5-lb weight loss No Fever BRBPR- mild

Physical examination Abdomen- soft Nontender No mass

SH Lived in Louisiana x 10 yrs

and just moved to Philadelphia

No Cigs

Laboratory values WBC: 8,500 cells/µL Hgb: 10.8 g/dL CRP: 10.0 mg/dL Albumin: 3.2 g/dL Negative - stool C & S, C diff

CRP = C-reactive protein;

RLQ = right lower quadrant

C & S- culture and sensitivity

C Diff- Clostridium Difficile

Case 2

Case 2: Pathology

Ova and Parasite Wet Mount

Need to BiopsyNeed to Biopsy

Qu Z, et. al . Human Pathology . 2009; 40, 572–577

ARS Question Case 2

Appropriate treatment options for this patient at this time includes (One single best answer):

1.) Anti TNF therapy

2.) Oral corticosteroid therapy

3.) High Fiber Diet and Bulk Laxative

4.) Efinaconazole

5.) Ivermectin

Strongyloides Colitis Strongyloides Colitis

Endemic areas : - Appalachian region States(especially in eastern Tennessee, Kentucky, and West Virginia) and Louisiana in the United States and Puerto Rico- Regions with large influx of tourists and emigrants from these endemic areas, southeastern Asia, and southern, eastern, and central Europe also have high incidence and prevalence of the disease .

Who Gets Disease: - The infection may remain clinically indolent.- When the host is immune-compromised, hyperinfection syndrome (i.e., larvae overload in

the lung and involvement of the rest of the gastrointestinal system) and

disseminated strongyloidiasis (i.e., involvement of other organs) occur with a mortality rate near 90% Qu Z, et. al . Human Pathology . 2009; 40, 572–577

Strongyloides Colitis Strongyloides Colitis

Qu Z, et. al . Human Pathology . 2009; 40, 572–577

Infectious Colitis that Mimics UC Infectious Colitis that Mimics UC

Rameshshanker R., et. al . World J Gastrointest Endosc 2012 June 16; 4(6): 201-211

Strongyloides Colitis Strongyloides Colitis

Treatment: - Ivermectin and thiabendazole have shown to be superior to albendazole.

- For those too sick to tolerate or absorb oral (PO) Ivermectin, rectal (PR) or subcutaneous (SC) dosing may be effective.

- Ivermectin should be administered daily until symptoms have resolved and until larvae have not been detected for at least 2 weeks.

Qu Z, et. al . Human Pathology . 2009; 40, 572–577

Patient Case 3

Female, age 55 yr; UC x 25yrs

New onset diarrhea x 2 months

Symptoms Suprapubic Pain Diarrhea (3-4 loose stools/day) No weight loss No Fever No BRBPR

Physical examination Abd- soft Nontender No mass

SH No cigs

Laboratory values WBC: 5,500 cells/µL Hgb: 13.9 g/dL CRP: 3.0 mg/dL Albumin: 4.3 g/dL Negative - stool C & S, C diff

Colonoscopy As per video

CT Enterography Normal Small bowel

CRP = C-reactive protein;

RLQ = right lower quadrant

C & S- culture and sensitivity

C Diff- Clostridium Difficile

Case 3

ARS Question Case 3

Appropriate treatment options for this patient at this time includes (One single best answer):

1.) Total proctocolectomy

2.) Endoscopic Mucosal Resection

3.) Segmental Colectomy

4.) Continued Surveillance every 6 months x 1 year then annual surveillance thereafter

Type III, IV and V : are considered to be features of neoplastic lesionsKudo S, et al Gastrointest Endosc. 1996;44:95–96.

Modified Kudo Criteria

UC: Conventional Polyps: Endoscopic Features Suggesting Malignancy

Central Umbilication Firm (or hard) consistency when the head is pushed with a snare or forceps Satellite Lesions Irregular surface contour Focal ulceration Broadening of the stalk

Patient Case 4

Female, age 48 yr; with constipation x 2yrs

New onset diarrhea x 2 months

Symptoms Suprapubic Pain Diarrhea (2-3 loose stools/day) 5-lb weight loss No Fever No BRBPR

Physical examination Abd- soft Nontender No mass

SH+ cigs 1 ppd x 5 yrs

Laboratory values WBC: 8,500 cells/µL Hgb: 13.8 g/dL CRP: 3.0 mg/dL Albumin: 4.3 g/dL Negative - stool C & S, C diff

Colonoscopy As per video

CT Enterography Normal

CRP = C-reactive protein;

RLQ = right lower quadrant

C & S- culture and sensitivity

C Diff- Clostridium Difficile

Case 4

Pathology

Pathology

ARS Question Case 4

Appropriate treatment options for this patient at this time includes (One single best answer):

1.) Anti TNF therapy

2.) Oral corticosteroid therapy

3.) High Fiber Diet and Bulk Laxative

4.) Topical Mesalamine

Solitary Rectal Ulcer Syndrome

Rectal ulcers may be single (25%) or multiple. Three types of lesions described

Ulcerative Polypoid Flat lesions

Most common type is ulcerative. A typical ulcer is shallow, with a white sloughy base

and a thin rim of erythematous and edematous mucosa Ulcers are typically located 4cm to 12 cm from the anal

verge and anterior to the anorectal junction.

Qing-Chao Zhu,, et al World J Gastroenterol 2014 January 21; 20(3): 738-744

Histopathologically characteristics of solitary rectal ulcer syndrome include: Fibrous obliteration of the lamina propria Disorientation with thickening of the muscularis

mucosa Regenerative changes with disorientation of the crypt

architecture.

Solitary Rectal Ulcer Syndrome

Qing-Chao Zhu,, et al World J Gastroenterol 2014 January 21; 20(3): 738-744

Pathophysiology

Repeated straining may lead to mucosal prolapse Puborectalis overactivity

Qing-Chao Zhu,, et al World J Gastroenterol 2014 January 21; 20(3): 738-744

Suggested Treatment

Qing-Chao Zhu, et. al . World J Gastroenterol 2014 January 21; 20(3): 738-744

Patient Case 5 Female, age 48 yr;

with new onset diarrhea x 2 weeks

Prior UC x 5 years in remission on 2.4 grams mesalamine (pancolitis)

Symptoms Suprapubic cramping prior to

defecation Diarrhea (2-3 loose stools/day) No weight loss No Fever No BRBPR

Physical examination Abd- soft Nontender

SHNo cigs , No Ethanol , no

Illicit drrugs Laboratory values

WBC: 4,900 cells/µL Hgb: 14.0 g/dL CRP: 2.0 mg/dL Albumin: 4.6 g/dL Negative - stool C & S, C diff

Colonoscopy As per video

CT Enterography Normal Small Bowel

CRP = C-reactive protein;

RLQ = right lower quadrant

C & S- culture and sensitivity

C Diff- Clostridium Difficile

Case 5

Case 5

ARS Question Case 4

The most likely etiology for this patients diarrhea is (One single best answer):

1.) Common Variable Immune deficiency associated with colonic lymphoma

2.) Colonic CMV Infection

3.) Melanosis Coli

4.) Lymphomatoid Papulosis of the colon

5.) Acute Colonic Crohn’s Disease

Melanosis Coli

Melanosis coli is well localized within the colon as there is usually no pigment deposition in the more proximal small intestine, including the ileum.

The pigment intensity is not uniform, being more intense in the cecum and proximal colon compared to the distal colon.

Mucosal lymphoid aggregates normally display a distinct absence of pigment producing a “starry sky” appearance, especially in the rectosigmoid region.

Freeman HJ , World J Gastroenterol 2008 July 21; 14(27): 4296-4299

Melanosis Coli

Although labeled as melanosis, electron microscopy and X-ray analytical methods have provided evidence that this pigment is not melanin at all, but lipofuscin.

Often, herbal remedies or anthracene containing laxatives are often historically implicated, and experimental studies in both humans and animal models have also confirmed the intimate relationship with these pharmacological or pseudo-pharmacological remedies.

Freeman HJ , World J Gastroenterol 2008 July 21; 14(27): 4296-4299

Melanosis Coli The appearance of melanosis coli during colonoscopy is

largely due to pigment granule deposition in macrophages located in the colonic mucosa.

Often detected during investigation for long-standing constipation, often in conjunction with a history of the chronic use of anthracene cathartics : cascara, senna, aloes and rhubarb

Freeman HJ , World J Gastroenterol 2008 July 21; 14(27): 4296-4299

Melanosis Coli The appearance of melanosis coli during colonoscopy is

largely due to pigment granule deposition in macrophages located in the colonic mucosa.

Often detected during investigation for long-standing constipation, often in conjunction with a history of the chronic use of anthracene cathartics : cascara, senna, aloes and rhubarb

Freeman HJ , World J Gastroenterol 2008 July 21; 14(27): 4296-4299

Melanosis Coli Described in patients with IBD

Pardi DS, J Clin Gastroenterol. 1998 Apr;26(3):167-70.

Melanosis Coli 5 patients with laxative use

Melanosis Location:

Pardi DS, J Clin Gastroenterol. 1998 Apr;26(3):167-70.