Cold snare polypectomy without submucosal injection: safety and efficacy in 615 large serrated lesions

Background and study aim Cold resection is becoming the standard of care for the resection of nonpedunculated colon lesions up to 10 mm in diameter. Sessile serrated adenomas/polyps (SSA/Ps), including those ≥ 10 mm, present various characteristics that make them ideal candidates for cold snare polypectomy (CSP). Patients and methods A prospectively maintained database was searched retrospectively for consecutive patients with lesions ≥ 10 mm resected between March 2013 and March 2018. During that period, all SSA/P-appearing lesions were resected using CSP without submucosal injection, except for lesions with endoscopic suspicion of dysplasia or submucosal invasion. Patients with a pathological diagnosis of SSA/P were included in the analysis. Adverse events were recorded up to 21 days following colonoscopy. Results 615 SSA/Ps ≥ 10 mm were resected during 452 colonoscopy procedures in 379 patients (mean age 54.1 years; standard deviation [SD] 11.9 years). Mean polyp size was 13.7 (SD 5.2) mm; 122 lesions (19.8 %) were ≥ 20 mm and 479 lesions (77.9 %) underwent piecemeal resection. Immediate adverse events included persistent abdominal pain that resolved spontaneously within 2 hours in three patients (0.8 %; 95 % confidence interval [CI] 0.2 %–2.3 %). One patient with persistent intraprocedural bleeding was successfully treated with a hemostatic clip. No late adverse events were detected. Surveillance colonoscopy was performed in 293 patients (77.3 %) at 23.4 (SD 11.6) months following index colonoscopy; residual/recurrent lesions were diagnosed in 23 patients (7.8 %; 95 %CI 5.0 %–11.6 %). Conclusion CSP without submucosal injection appeared to be safe and effective for the resection of large SSA/Ps.

Evaluation of Diagnostic, Prognostic Indicators and Surgical Outcome in 20 Cases Treated for Equine Intestinal Colic

Background: Colic is one of the most common and challenging problem encountered by equine practitioners. In practise majority of horses suffering from colic can be treated with medical management but around 10% of horses with colic require surgical intervention in an effort to save the life of animal. In India, equine abdominal surgery is not popular because there is lack of infrastructure, manpower and expertise therefore, there is a need to conduct clinical studies to document outcome of equine colic cases managed surgically. The present report describes diagnostic, prognostic indicators and post-operative outcome of exploratory celiotomy performed to manage various cases of colic surgical outcome of colic surgery in Indian horse breeds.Methods: The present study was conducted on 20 horses having intestinal colic (n=20). The affected patients were selected for exploratory celiotomy on an emergency basis having moderate to severe persistent abdominal pain, lack of response to medicinal treatment with absence of intestinal borborygmi. Preoperative physical assessment, biochemical analysis and peritoneal fluid analysis were done in all the clinical cases. The preoperative physical assessment and various blood parameter estimation helped in decision making.Conclusion: The result of intestinal colic cases showed that mean heart rate and respiration rate (mean±SE) were significantly higher in non-survivors as compared to survivors. Blood lactate level was significantly higher in non survivors than survivors. Large colon affectation (n=8) were the primary cause of the colic, followed by small colon (n=6), cecum (n=3) and small intestine (n=3). Postoperative complications were peritonitis and ileus (n=6), subcutaneous seroma (n=7), pyrexia (n=4), diarrhoea (n=6). Short term survivability in intestinal colic patients was 55% and long term survivability was 50%.

Late mesenteric ischemia after Sars-Cov-2 infection: case report

The purpose of this article is to report the case of a 53-year-old black man, with no previous comorbidities, who presented 48 days after a confirmed diagnosis of COVID-19, complaining of an initially insidious epigastric pain that had progressed to severe pain radiating to the interscapular vertebral region, with hyporexia and episodes of projectile vomiting, with no nausea or fever. Laboratory tests revealed no signs of acute infection or pancreatic injury. Abdominal computed tomography showed dilated, fluid-filled small bowel loops with thickened walls. After clinical treatment, the patient developed persistent abdominal pain. An exploratory laparotomy was performed, finding two sites of small bowel stenosis, with no extrinsic cause, and signs of local ischemia and considerable distension of jejunal and ileal loops. After enterectomy and side-to-side enteroanastomosis, the patient recovered satisfactorily and was discharged with a prescription for oral anticoagulants for outpatient use.

Malato! Non pazzo

An adolescent with persistent abdominal pain and stipsis, previously diagnosed as Gastrointestinal Functional Disorders (FGD), was finally diagnosed as affected by ulcerative colitis. The author underlines that the diagnosis of FGD should always be questioned when one or more red flag (such as weight loss or blood in the stool) is present.

Sickle cell trait: a cause of abdominal pain and pulmonary embolism

Introduction: Sickle cell trait (SCT) is a rare and underdiagnosed disorder in the Argentinian population. In this condition, individuals carry the mutation of the HbS gene in one of the two beta-globin genes. In general, SCT does not present with the typical manifestations of sickle cell anemia. However, under certain circumstances, some clinical characteristics of the disease may develop. Methods: We discussed the case of a 39-Year old man who presented with persistent abdominal pain of unknown origin after traveling to a high-altitude place. He underwent laparotomy without a definite diagnosis. After that, the patient developed signs of splenic infarction and pulmonary thromboembolism that were confirmed by computed tomography. Results: A sickling test was positive, and a hemoglobin electrophoresis revealed an abnormal fraction at the HbS level. In this context a diagnosis of SCT was made. Additional, tests revealed a strongly positive lupus anticoagulant. Conclusion: SCT presentation as abdominal pain and thromboembolic disease in adult patients after exposure to high altitudes is a rarely suspected diagnosis.

A Rare Case of Colonic Sarcoidosis Presenting as a Mass

Introduction. Sarcoidosis is a common multisystem chronic inflammatory disease of an unidentified inciting etiology. The most common initial manifestations of this disease involve the pulmonary system, and involvement of the gastrointestinal tract is rare. Sarcoidosis of the gastrointestinal tract occurs in an oral-anal gradient, with the esophagus and stomach being the most commonly involved sites, while colonic involvement remains extremely rare. Case Presentation. We present a case of a 24-year-old African American man who was evaluated for persistent abdominal pain, chronic diarrhea, and weight loss. Workup for infectious etiologies and celiac disease was unrevealing. An inflammatory mass in the hepatic flexure was found during colonoscopy, and a computed tomography (CT) scan of the abdomen was significant for circumferential thickening of the cecum and ascending colon, along with nodular thickening of the peritoneum without enhancement. Malignancy and inflammatory bowel disease were the initial differentials. A peritoneal biopsy was also performed. Pathology of the colon and peritoneal biopsy was significant for the presence of noncaseating granulomas and confluent granulomatous inflammation. The patient was diagnosed with colonic sarcoidosis, and treatment with corticosteroids was initiated. Symptoms resolved with treatment, and a follow-up colonoscopy five months later showed interval healing. Conclusion. Although rare, colonic sarcoidosis should be considered as one of the differential diagnoses when evaluating a patient with chronic diarrhea and a mass on colonoscopy. Histopathology is the key to diagnosis as it distinguishes malignancy from sarcoidosis. Corticosteroids remain as an option for treating colonic sarcoidosis.

How to Suspect and Manage an Hypoplasic Gallbladder: A Case Report and Review of Literature

Background: Malformations related to the gallbladder are uncommon, with an incidence lower than 0,1%. The majority of them are asymptomatic, however when symptoms appear are non-specific with a similar presentation to biliary colic. Methods: We report a case of a 29-year-old woman with persistent upper right abdominal pain and no visualization of the gallbladder in the ultrasound (US), CT scan or in the magnetic resonance cholangiopancreatography (MRCP). Results: A laparoscopic exploration was performed due to persistent abdominal pain which confirmed an hypoplasic gallbladder. After cholecystectomy, symptoms were relieved. Herein we propose a decisional algorithm when suspecting a gallbladder with agenesis or hypoplasia. Conclusion: Surgeons need to take into consideration congenital anomalies of the gallbladder. Performing imaging techniques is important in order not to misdiagnose hypoplasia.

Metastatic leiomyosarcoma of the excluded stomach: a case report

Background: Leiomyosarcoma (LMS) represents about 1% of primary malignancies of the stomach, usually evolves with hepatic implants in 2-thirds of cases, and the outcome is frequently poor. With an insidious course, late diagnosis and misdiagnosis with other gastric neoplasia occur. Immunohistochemical evaluations are mandatory to confirm the diagnostic hypothesis. Surgical resection has been the more effective treatment of gastric LMS; however, recurrences after resections and distant metastases may develop in up to 50% of the patients. Doxorubicin, gemcitabine, and docetaxel are therapeutic options, with variable responses. Case presentation: The 52-year-old male herein described with a diagnosis of LMS in the gastric pouch and liver metastasis underwent a Roux-en-Y bypass to treat morbid obesity more than a decade ago. Persistent abdominal pain was a unique symptom, and he had liver metastasis at diagnosis. The initial hypothesis was a metastatic gastrointestinal stromal tumor (GIST) of the excluded stomach and the patient underwent a schedule with imatinib without significant response. After a complete revision of the anatomopathological findings, the patient underwent a new biopsy of the gastric mass, and the immunohistochemical data were consistent with LMS. Then doxorubicin replaced imatinib, later changed by gemcitabine associated with docetaxel. As last control found lesions in the central nervous system, he is under radiotherapy sessions. Conclusion: The diagnosis of gastric LMS often occurs at late stages because of the insidious clinical course. The rate of liver metastasis at diagnosis is high. Besides, the relatively poor response to the alternative management for non-surgical stages of the disease yields severe outcomes.