An elusive lesion in the colon 

How to ensure detection of subtle lesions during screening colonoscopy?

A 55-year-old female patient with no family history of colorectal cancer (CRC) underwent a scheduled screening colonoscopy. The colonoscopy was performed by an experienced endoscopist (adenoma detection rate [ADR] of 54%), using a high-resolution colonoscope with narrow-band imaging (NBI) cabaility. Carbon dioxide was used for bowel insufflation. The patient was sedated with midazolam and propofol, with adequate oxygen supplementation and continuous monitoring of her blood pressure and oxygen saturation. The video shows the colonoscopy and two photos (figure 1) are provided of the ascending colon and of the area near the hepatic flexure during withdrawal of the scope.

 Figure 1 | Images of the ascending colon and of the area near the hepatic flexure during withdrawal of the colonoscope under conventional white-light and narrow-band imaging conditions. 

Case Question 1: 

Which of the following statements is correct?
A. There is a serrated lesion without dysplasia
B. There is a serrated lesion with dysplasia
C. There is an adenoma with low-grade dysplasia 
D. There is an adenoma with high-grade dysplasia

Case Question 2:

What is the minimum length of time you should spend inspecting the right colon (including the cecum, ascending colon and hepatic flexure)?
A. 3 minutes
B. 4 minutes
C. 5 minutes
D. 6 minutes

Case Question 3:

Which of the following is more likely to increase the adenoma detection rate (ADR)?
A. Better training 
B. Chromoendoscopy
C. A mucosal exposure device/cap
D. All of the above 

A rare biopsy finding with many possible causes

What's causing epigastric abdominal pain and nausea in this 55-year-old man?

A 55-year-old man was referred to our general gastroenterology clinic by colleagues from the renal transplant unit for evaluation of persistent epigastric abdominal pain and nausea that had been present for the past 6 months and had started to interfere with his quality of life. 

The patient’s past medical history included allogeneic renal transplantation 3 years prior, secondary to progressive hypertensive kidney disease. His current immunosuppression regimen was mycophenolate mofetil, cyclosporine, everolimus and steroids, while his hypertension was being controlled with nebivolol. The only other drug taken on a regular basis was oral iron supplementation to manage mild hypochromic anaemia. His symptoms had failed to resolve with a proton pump inhibitor (PPI) trial administered by a gastroenterologist in private practice. He had also undergone noninvasive testing (urea breath test) for the presence of Helicobacter pyloriinfection, with the result being negative. He denied weight loss, vomiting, changes in bowel habit, fever or any other accompanying symptoms in the same time period as his main complaints. No significant information was elicited from his family or regarding his social history (including travels and sexual behaviour).  Physical examination findings were unremarkable. The patient had recently undergone blood tests that revealed no significant changes from his previous baseline values. In view of the above symptoms and history an upper gastrointestinal endoscopy was scheduled and performed. The endoscopic findings included erythema with small erosions of the gastric mucosa. Multiple biopsy samples were obtained from areas with findings and also from macroscopically normal mucosa. Histological findings are shown in figure 1. Figure 1 | Histological findings in the stomach of the case patient. Haematoxylin and eosin (H&E) staining. Magnification x400. 

Case Question 1

WHAT IS THE HISTOLOGICAL DIAGNOSIS? A.     MALT lymphoma B.     H. pylori-associated chronic gastritis C.     Granulomatous gastritis D.    Gastric adenocarcinoma E.     Collagenous gastritis

Case Question 2      

IN VIEW OF THE PAST HISTORY OF THIS PATIENT, WHAT WAS THE UNDERLYING CAUSE OF THE SYMPTOMS OBSERVED?  A.    Sarcoidosis B.    Granulomatosis with polyangiitis C.    Crohn’s disease D.   Tuberculosis E.    Histoplasmosis F.    A drug-induced reaction G.   Helicobacter pyloriinfection H.   Whipple’s disease

Case Question 3

HOW SHOULD WE PROCEED REGARDING THE MANAGEMENT OF THIS PATIENT? A.    Acid suppression with PPIs B.    Investigate other possible causes C.    Stop iron supplementation and take repeat biopsy samples D.   Stop iron supplementation and investigate other possible causes

An incidental diagnosis by endoscopic ultrasound

What has been detected by follow-up EUS in a patient with a multifocal IPMN?

An asymptomatic 66-year-old male patient with a multifocal intraductal papillary mucinous neoplasm (IPMN) underwent a follow-up EUS examination with a linear array echoendoscope. His medical history included diabetes, hypertension and smoking. While advancing the echoendoscope in the oesophagus, the endoscopic ultrasound (EUS) image shown was captured.

WHAT IS YOUR DIAGNOSIS? A. Oesophageal duplication cyst B. Aortic aneurism C. Mediastinal cyst D. Aortic dissection

A not-so-black-and-white case of gastrointestinal bleeding

What's causing the black tarry stool, episode of coffee-ground emesis and epigastric pain?

A 60-year-old woman presents at the Emergency Department complaining that she has been passing black, tarry stool since yesterday and had an episode of coffee-ground emesis some hours ago. It is the first time she has noticed these kinds of symptoms. Moreover, she reports episodes of epigastric pain on and off during the past week.

The patient has never undergone endoscopy. Her medical history includes diabetes mellitus, hypertension, hyperlipidaemia, gastro-oesophageal reflux disease (GORD), osteoarthritis and alcohol abuse. She admits that she occasionally uses nonsteroidal anti-inflammatory drugs (NSAIDs) to cope with episodes of pain caused by her osteoarthritis and that she took some in the past week. On physical examination she is tachycardic (92 beats per minute) and hypotensive (82/57 mm Hg), but afebrile and her oxygen saturation level is normal. Her abdomen is mildly distended, with some tenderness during deep palpation and increased bowel sounds. Her blood test results at presentation are shown in Table 1. A variceal bleed was suspected, and an emergency upper gastrointestinal endoscopy was performed (see video).   Case Question 1  WHAT IS YOUR CLINICAL DIAGNOSIS? A. Oesophageal melanoma
B. Oesophageal infection (e.g. CMV, HSV, Candidiasis)
C. Acanthosis nigricans
A. Diabetes mellitus
B. NSAID use
C. Alcohol abuse 
D. Hypoalbuminemia
E. Hypertension
A. Nil per os
B. Aggressive fluid resuscitation
C. Antibiotics 
D. IV acid suppression with PPIs
E. Glycaemic control

Yet another case of abdominal pain? 

A 41-year-old man with a recent history of weight loss, reduced appetite and nausea... 

A 41-year-old man with a recent history of weight loss, reduced appetite and nausea presents with acute abdominal pain.

On physical examination he has abdominal distension without tenderness but pain during deep palpation, Blumberg’s sign is negative and bowel sounds are sparse. The initial radiography findings are shown in figure 1 and his blood test results are shown in table 1.  Table 1 | Blood test results at presentation. Click on the picture to enlarge the table. At this stage, would you choose to give laxatives and discharge the patient, urgently perform a CT scan or endoscopy, or give a prokinetic, antibiotics, laxatives and monitor the patient every 6h? The correct decision here is to perform a CT scan, which is what the case patient underwent—the findings are shown in figure 2.  Figure 2 | Abdominal contrast-enhanced CT scan with coronal and sagittal reconstructions; images were acquired at portal venous time (about 70 seconds after injection of iodinated contrast medium).

Case Question 1

b) Crohn’s Disease
c) Intussusception
d) Megacolon

A case at the crossroads of dermatology and gastroenterology

What next for a middle-aged patient with a condition affecting her skin and mouth? 

Several years ago, a middle-aged woman presented with a condition affecting her skin (photograph A) and mouth (photograph B), and she was diagnosed with lichen planus.

The patient then presented with dysphagia. A lesion was found high in the oesophagus (photograph C) and biopsy samples were taken (photograph D). Case question 1 WHAT IS THE AETIOLOGY OF THE STRICTURE? a) Benign b) Malignant 

Pretty but probably poisonous    

What is the most likely histology of the lesion?

The beautiful polyp shown in the photograph (figure 1) was found in the rectum of a middle-aged man who was on a polyp surveillance programme.

WHAT IS THE MOST LIKELY HISTOLOGY OF THE LESION? a)    Hyperplastic polyp b)    Tubular adenoma c)     Tubulovillous adenoma d)    Villous adenoma e)    Traditional serrated adenoma

Possible pancreatitis or could it be cancer?

A retired man with an unusual cause of jaundice...

A 65-year-old man presents with obstructive jaundice. He admits to drinking up to half a bottle of wine every day. The photograph shows the findings of the abdominal CT that is organised (figure 1).  Subsequently, an endoscopic retrograde cholangiopancreatography (ERCP) is arranged to place a common bile duct (CBD) stent and obtain ampullary biopsy samples. Unfortunately the obstruction, just distal to the first part of the duodenum, prevents access to the papilla (figure 2).

WHAT IS THE LIKELY DIAGNOSIS? a)     Acute pancreatitis b)     Autoimmune pancreatitis c)     Chronic pancreatitis d)     Carcinoma of the head of the pancreas e)     Duodenal adenocarcinoma

Confusion over a rectal biopsy sample

How would you manage this nodule?    

The nodule shown in the photograph was found in the rectum of an elderly, asymptomatic patient undergoing a gastroscopy and colonoscopy because of mild iron-deficiency anaemia (figure 1). Biopsy samples were taken from the nodule and the H&E stain is shown (figure 2).

HOW WOULD YOU MANAGE THIS NODULE? a)     Ignore the polyp b)     Sample it again c)     Remove it by endoscopic mucosal resection d)     Remove it by endoscopic submucosal dissection e)     Remove it surgically

A coeliac conundrum

What would you do next for this middle-aged woman previously diagnosed with coeliac disease?

A middle-aged woman presented with loose stool and weight loss. Initially, she refused an endoscopy and a diagnosis of coeliac disease was made on the basis of a high tissue transglutaminase (tTG) antibody titre. She was started on a gluten-free diet (GFD) but her symptoms remained despite adherence to the GFD. After several months she agreed to undergo an endoscopy. The images show the endoscopic view of the duodenal mucosa (figure 1) and the corresponding histology slide (figure 2) stained with haemotoxylin and eosin (H&E).

WHAT WOULD YOU DO NEXT? a)     Refer the patient for a dietary review b)     Request a clonal analysis of the intraepithelial lymphocytes c)     Refer for HLA DQ2/DQ8 testing d)     Refer the patient for capsule endoscopy e)     Add prednisolone to the dietary restrictions

An interesting ileal finding

What are the treatment options for this lesion discovered during colonoscopy?

A 50-year-old woman is undergoing a colonoscopy because of loose stool. When the tip of the endoscope enters the terminal ileum, the lesion in the photograph is found. The patient asks you if any treatment will be necessary.

WHAT DO YOU TELL THE PATIENT? a)     The lesion is likely to be a lipoma and can probably be ignored b)     The lesion is likely to be adenomatous and should be removed by endoscopic mucosal resection (EMR) c)     The lesion is likely to be a neuroendocrine tumour (NET) and should be removed surgically d)     The lesion is likely to be a gastrointestinal stromal tumour (GIST), requiring annual surveillance e)     None of the above 

The hot PET

Hot spots in the descending colon. What would you do with the polyps found on subsequent colonoscopy?

A 72-year-old man previously presented with obstructive bowel symptoms. He was diagnosed with mantle cell lymphoma—a type of non-Hodgkin lymphoma—with involvement of the rectosigmoid junction and terminal ileum.

He underwent a left hemicolectomy and resection of the terminal ileum followed by chemotherapy (fludarabine, mitoxantrone, dexamethasone and rituximab). After treatment he went into prolonged remission and follow-up colonoscopies 5 years and 7 years later were both unremarkable. The findings of a gastroscopy and capsule endoscopy were also normal 7 years after treatment, at which time the patient was asymptomatic with normal blood results. His haematologist requested a surveillance FDG PET-CT scan, which demonstrated a hot spot in the descending colon (figure 1). A further colonoscopy was carried out and showed 2 polyps in the descending colon (figure 2; DC1 [15mm] and DC2 [50 mm]). The ileocolonic anastomosis and neoterminal ileum were both unremarkable. WHAT WOULD YOU DO WITH THESE POLYPS? a)     Ignore them, as they are inflammatory. b)     Take biopsy samples only. c)     Perform standard snare polypectomy. d)     Organise an endoscopic mucosal resection (EMR). e)     Organise an endoscopic submucosal dissection (ESD).

Quick or Quincke's thinking?

What next for a patient who's recently been feeling unwell & passing black stools?

A 40-year-old male patient went to his local A&E department with a short history of feeling unwell and passing black stools. He had a past history of chronic pancreatitis that was attributable to alcohol and a bleeding peptic ulcer some 15 years earlier. He was not taking any medication. On admission, the patient was pale with a heart rate of 75 BPM and his blood pressure was 125/80 mm Hg. The patient’s Hb level was 36 g/L, with a mean corpuscular volume of 8.93, iron 1.253 mmol/L and ferritin 0.27 pmol/L. On endoscopy, the oesophagus and stomach were unremarkable and the photographs show the appearance of the duodenal ampulla (figure 1a–c).

WHAT WOULD YOU DO NEXT? a)     Endoscopic retrograde cholangiopancreatography (ERCP) b)     Percutaenous transhepatic cholangiogram c)     Abdominal computed tomography (CT) d)     Angiogram e)     Abdominal ultrasound

A curious case of colitis

What type of colitis would you diagnose?

A 45-year-old Chinese woman presented with a 2-year history of intermittent loose stools, occasional PR bleeding and abdominal pain. The mucosal patches seen on the photograph were found in the left side of the colon. A full set of mucosal biopsy samples were taken and a representative histology slide, stained with H&E, is also shown.

WHAT IS THE MOST LIKELY DIAGNOSIS? a)    Schistosomal colitis b)    Crohn’s colitis c)    Ulcerative colitis d)    Ischaemic colitis e)    Amoebic colitis

An incidental gastric finding

What would you diagnose in this elderly, overweight man with diabetes and iron deficiency anaemia?

The lesion in the photographs was noted in the stomach of an overweight 70-year-old man with diabetes who was undergoing gastroscopy because of iron deficiency anaemia.

WHAT IS YOUR ENDOSCOPIC DIAGNOSIS? a)    Lymphangiectatic cyst b)    Small gastrointestinal stromal tumour (GIST) c)    Small leiomyoma d)    Xanthelasma e)    Small signet ring cell carcinoma

A scary looking polyp

What would you do if you found this polyp in the high rectum of an elderly patient?

These four photographs show a polyp that was found in the high rectum of an elderly patient.

WHAT WOULD YOU DO NEXT? a)     Take a full set of samples and wait for histology findings b)     Take samples and request an endoscopic ultrasound (EUS) c)     Take samples and request staging X-rays d)     Resect the polyp endoscopically e)     Refer the polyp for transanal resection

Damned if you do and damned if you don’t

How would you manage this polyp in the setting of ulcerative colitis?

The photograph shows a transverse colonic polyp that was found in a 55-year-old man who was under surveillance because of a 15-year history of ulcerative colitis. Analysis of biopsy samples has indicated that the polyp is a tubular adenoma harbouring low-grade dysplasia.

a) This is probably a sporadic polyp that can be removed endoscopically.
b) Offer endoscopic resection only if analysis of a full set of random mucosa samples, taken throughout the colon, does not reveal any flat invisible dysplasia.
c) Endoscopically, this is a dysplasia-associated lesion or mass (DALM), but an endoscopic attempt at resection would nevertheless be appropriate.
d) The concept of a DALM is outdated and an attempt at endoscopic resection should be undertaken.
e) This patient should be offered a pan-proctocolectomy with ileo-anal pouch anastomosis.

Reassure, resect or retreat?

What's the diagnosis and management of this nodule likely to be?

This video clip shows a nodule that was found on the greater curve of the stomach in a 35-year-old man referred for a gastroscopy because of symptoms of reflux oesophagitis.

You take a full set of samples and after the examination the patient asks what the management of the lesion is likely to be.

What do you tell the patient? a) This is probably a hyperplastic polyp and eradication of any Helicobacter pylori may well induce spontaneous regression. You tell the patient that he will most likely be offered another examination in a year to reassess the stomach after treatment to eradicate Helicobacter pylori. b) This is probably a gastrointestinal stromal tumour (GIST). You tell the patient that he is likely to be offered an assessment by endoscopic ultrasonography (EUS) and, as the lesion is small, it is likely that surveillance will be offered. c) This is probably a neuroendocrine tumour (NET). You tell the patient that it is likely to require surgical resection. d) This is probably an early gastric cancer. You tell the patient that he is likely to be offered an attempt at endoscopic resection. e) This is probably an advanced gastric cancer. You tell the patient that he is likely to be offered a gastrectomy. 

KRAS or BRAF—that is the question

What's causing the altered bowel habits in this elderly patient?

The photograph shows a lesion that was found in the ascending colon of a 75-year-old man who was undergoing colonoscopy because of a change in bowel habit.

a) Hyperplastic polyp
b) Sessile serrated polyp
c) Traditional serrated adenoma
d) Mixed hyperplastic polyp
e) Tubulovillous adenoma
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