Transcript Natural History of Dysplasia

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,
 SH
with UC x 2 yrs. On
 Lived in Louisiana x 10 yrs
maintenance mesalamine 4.8
and just moved to
grams x 1.5 years
Philadelphia
 No Cigs
New onset diarrhea x 2
months
 Symptoms
 Laboratory values





Suprapubic Pain
Diarrhea (3-5 loose stools/day)
5-lb weight loss
No Fever
BRBPR- mild





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
 Physical examination
 Abdomen- soft Nontender
 No mass
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
Case 1
How Do You Report This ?
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
Case 1
Trichuris Trichiura: Whipwom
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
Case 1
Trichuris Trichiura: Whipwom
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 fecescontaminated food
Source: http://www.cdc.gov/paorm/- accessed 12/04/2014
Case 1
Trichuris Trichiura: Whipwom
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:
body
- Anthelminthic medications (drugs that rid the
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,
 SH
with UC x 2 yrs. On
 Lived in Louisiana x 10 yrs
maintenance mesalamine 4.8
and just moved to
grams x 1.5 years
Philadelphia
 No Cigs
New onset diarrhea x 2
months
 Symptoms
 Laboratory values





Suprapubic Pain
Diarrhea (3-5 loose stools/day)
5-lb weight loss
No Fever
BRBPR- mild





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
 Physical examination
 Abdomen- soft Nontender
 No mass
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 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
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
Qu Z, et. al . Human Pathology . 2009; 40, 572–577
Infectious Colitis that Mimics UC
Rameshshanker R., et. al . World J Gastrointest Endosc 2012 June 16; 4(6): 201-211
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
Modified Kudo Criteria
Type III, IV and V : are considered to be features of neoplastic lesions
Kudo S, et al Gastrointest Endosc. 1996;44:95–96
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
Solitary Rectal Ulcer Syndrome
 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.
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;
 SH
with new onset diarrhea x
No cigs , No Ethanol , no
2 weeks
Illicit drrugs
 Prior UC x 5 years in
 Laboratory values
remission on 2.4 grams
 WBC: 4,900 cells/µL
mesalamine (pancolitis)
 Hgb: 14.0 g/dL
 CRP: 2.0 mg/dL
 Symptoms
 Albumin: 4.6 g/dL
 Suprapubic cramping prior
to defecation
 Negative - stool C & S, C diff
 Diarrhea (2-3 loose
 Colonoscopy
stools/day)
 As per video
 No weight loss
 CT Enterography
 No Fever
 Normal Small Bowel
 No BRBPR
 Physical examination
 Abd- soft Nontender
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 pseudopharmacological 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 longstanding 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 longstanding 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.