1. Endoscopy Unknowns Gary R Lichtenstein, MD Director, Center for IBD University of Pennsylvania School of Medicine Hospital of the University of PA Philadelphia, PA

2. 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

3. 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

4. How Do You Report This ? Case 1

5. 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

6. Trichuris Trichiura: Whipwom Case 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 12/04/2014http://www.cdc.gov/parasites/whipworm/-

7. Trichuris Trichiura: Whipwom Case 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 12/04/2014http://www.cdc.gov/paorm/-

8. Trichuris Trichiura: Whipwom Case 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 12/04/2014http://www.cdc.gov/parasites/whipworm/-

9. 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

10. Case 2

11. Case 2: Pathology Ova and Parasite Wet Mount

12. Need to Biopsy Qu Z, et. al. Human Pathology. 2009; 40, 572–577

13. 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

14. 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

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

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

17. 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

18. 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

19. Case 3

20. 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

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

22. 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

23. 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

24. Case 4

25. Pathology

27. 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

28. 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

29.  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

30. 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

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

32. 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  SH No 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

33. Case 5

35. 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

36. 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

37. 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

38. 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

39. 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

40. Melanosis Coli  Described in patients with IBD Pardi DS, J Clin Gastroenterol. 1998 Apr;26(3):167-70.J Clin Gastroenterol.

41. Melanosis Coli  5 patients with laxative use  Melanosis Location: Pardi DS, J Clin Gastroenterol. 1998 Apr;26(3):167-70.J Clin Gastroenterol.