Colonic adenocarcinoma associated with colitis cystica profunda

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A 44-year-old man with paranoid schizophrenia was referred for colonoscopy for evaluation of intermittent bloating, constipation, and abdominal distention. His medical history was remarkable for previously treated Helicobacter pylori peptic ulcer disease, smoking, and bronchitis. His medications included benztropine, gabapentin, olanzapine, escitalopram, quetiapine, omeprazole, senna, and albuterol. Previous attempts at colonoscopy were incomplete due to retained solid stool at the hepatic flexure despite standard bowel preparation. On physical examination, his abdomen was soft but distended and measured 123 cm in circumference, and tympany was elicited in the left lower and right upper quadrants. After cleansing with an intense 2-gallon polyethylene glycol regimen, a repeat colonoscopy was attempted, but the instrument could not be advanced beyond the hepatic flexure because of tortuosity and angulation of the bowel (A). Evaluation of the colon mucosa was unremarkable except for a small adenomatous polyp that was removed from the transverse colon. Subsequent double-contrast barium enema revealed redundancy of the sigmoid

colon (B) and no lesions in the right colon or cecum. Review of the patient’s prior imaging studies revealed air under his right diaphragm (C), with haustral markings of interposed colon. He was diagnosed with Chilaiditi syndrome, which was thought to account for his symptoms, physical findings, and the technical difficulty in completing the colonoscopy.

DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Grigoriy E. Gurvits, MD, Nancy Lau, MD, Nicholas Gualtieri, MD, James G. Robilotti, MD, Department of Gastroenterology, St. Vincent’s Medical Center/New York Medical College, New York, New York, USA doi:10.1016/j.gie.2008.12.238

Commentary Dimitrius Chilaiditi was a Viennese born and educated radiologist of Greek origin whose name lives on because of his 1910 report of 3 patients who had intestine interposed between the liver and the right hemidiaphragm. In most patients, the interposed bowel is hepatic flexure, ascending or transverse colon, but it can be the small intestine, either alone or in combination with the colon. Chilaiditi’s sign is relatively rare, and can be intermittent, with a prevalence in the general population of 0.025% to 0.28%. Such hepatodiaphragmatic interposition usually is asymptomatic and identified incidentally on radiologic studies. Symptoms of abdominal pain, distention, vomiting, constipation, or dyspnea warrant the term Chilaiditi syndrome. Chilaiditi’s sign can occur in children but is more common in older adults and considered an acquired condition with increased prevalence in cirrhosis, chronic obstructive pulmonary disease, near-term pregnancy, and mental retardation. Recognition of the sign is mandatory before percutaneous transhepatic procedures, eg, liver biopsy, to avoid intestinal injury, and also before colonoscopy, which must be performed with great caution, lest administered air gets progressively trapped by an acutely angulated segment of bowel and perforation results. This is a perfect situation in which to use carbon dioxide as the insufflating agent: it is nonexplosive, rapidly absorbed, and increases colon blood flow. Differential diagnosis includes volvulus (which can occur in association with Chilaiditi’s sign), pneumoperitoneum (which can result from either Chilaiditi’s sign or colonoscopy), and diaphragmatic hernia. Yes, the presence of the interposed loop probably did make the colonoscopy challenging, but the colonoscopist is lucky it was not the surgeon who said there were no polyps in the dilated loop. Lawrence J. Brandt, MD Associate Editor for Focal Points

Colonic adenocarcinoma associated with colitis cystica profunda

A 41-year-old man with anemia had a colonoscopy that revealed a submucosal tumor 12 mm in diameter with reddish mucosa in the transverse colon (A). Endoscopic examination with narrow-band imaging revealed a neoplastic irregular vascular pattern (B), and EUS showed a submucosal hypoechoic nodule with thick mucosal layer (C). The lesion was resected by EMR. Histologic examinawww.giejournal.org

tion showed a dilated mucin-containing cyst lined by normal columnar epithelial cells in the submucosal layer (D, arrowheads, H&E, orig. mag. 2), and a well differentiated adenocarcinoma (D, arrow) in a high-grade tubular adenoma in the mucosal layer. Both the adenocarcinoma and tubular adenoma were strongly positive for Ki-67 and p53 by immunohistochemistry. In contrast, epithelial cells

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At the Focal Point

lining the cyst were partly positive for Ki-67 but negative for p53.

DISCLOSURE All authors disclosed no financial relationships relevant to this publication.

Makoto Mitsunaga, MD, Motoyoshi Izumi, MD, Takashi Uchiyama, MD, Aya Sawabe, MD, Emiko Tanida, MD, Kunihiro Hosono, MD, Tsuyoshi Abe, MD, Keigo Shirahama, MD, Akira Kanesaki, MD, Mitsufumi Abe, MD, Department of Internal Medicine, Machida Municipal Hospital, Tokyo, Japan doi:10.1016/j.gie.2008.12.240

Commentary There are 2 types of cystic dilation of colonic mucus glands: colitis cystica superficialis (CCS), and colitis cystica profunda (CCP). CCS almost always occurs with pellagra, but has been seen to complicate tropical sprue and leukemia, whereas CCP has been associated with a variety of ulcerating diseases including inflammatory bowel disease (ulcerative colitis, Crohn’s disease), in760 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 3 : Part 2 of 2 : 2009

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fectious colitis, rectal prolapse, and solitary rectal ulcer, among others. In CCS, the cysts are tiny and distributed along the length of the colon, whereas in CCP, cysts may be quite large, and are localized to the rectosigmoid, usually 6 to 7 cm from the anal verge. Presentations of CCP are those of rectal bleeding, mucorrhea, diarrhea, and even colonic obstruction dmuch like those of the disorders with which it may be associated. CCP is another of the great imitators and may resemble adenoma, adenocarcinoma, lipoma, endometriosis, neurofibroma, pseudopolyps, and pneumatosis coli. As in this case, it also may occur adjacent or subjacent to the diseases it resembles, including adenocarcinoma. A word of caution to the pathologist also, because in addition to fibrosis of the lamina propria and hypertrophic muscle fibers (changes characteristic of SRUS), these lesions histologically are typified by displacement of colonic glands into the submucosa, and, on occasion, may be mistaken for carcinomatous spread. Oh, how the complexities of mimicry, association, and perhaps causation give us the variations in our daily work that continue to make our jobs exciting and rewarding. As for the patients, however, early and precise diagnosis is key to better outcome. Lawrence J. Brandt, MD Associate Editor for Focal Points

Missed appendiceal adenocarcinoma diagnosed preoperatively by endoscopy with an attached transparent hood

A 73-year-old woman was seen at our hospital because of pain in the right lower quadrant of the abdomen. She was diagnosed as having appendicitis, and her symptoms improved with antibiotic therapy. Stool culture before antibiotic administration was negative. Two weeks later, an abdominal CT scan showed an appendiceal tumor (45 mm), but colonoscopy showed only cecal inflammawww.giejournal.org

tion and an edematous terminal ileum; biopsy specimens from both sites showed no evidence of malignancy. A follow-up CT scan 4 months later showed reduction of the cecal tumor. Gynecologic examination showed normal results. Three months later, the patient noticed a mass in the right lower abdominal quadrant. A CT scan showed a tumor that measured 30 mm in diameter in the ileocecal

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