Colonic polyposis

nn Interface EndoscopyInterface Endoscopy
nn Magnification chromoendoscopy.Magnification chromoendoscopy.
nn NBI.NBI.
nn AFI.AFI.
nn OCT.OCT.
nn LaserLaser--scanningscanning confocalconfocal microscopy.microscopy.
nn Raman Spectroscopy.Raman Spectroscopy.
nn Light scattering spectroscopy.Light scattering spectroscopy.
nn BioendoscopyBioendoscopy..

MagnificationMagnification
ChromoendoscopyChromoendoscopy
nn Allows fine topographical details to be seen.Allows fine topographical details to be seen.
nn Scopes available from x8 to x170 magnification.Scopes available from x8 to x170 magnification.
nn Lens has to be close to surface of mucosa (interface)Lens has to be close to surface of mucosa (interface)
due to narrow range of focus.due to narrow range of focus.
nn With dye (MB or LI) healthy mucosa isWith dye (MB or LI) healthy mucosa is
homogenously stained, non healthy mucosahomogenously stained, non healthy mucosa
heterogeneous pattern or not stained.heterogeneous pattern or not stained.
nn Allows differentiation ofAllows differentiation of adenomatousadenomatous fromfrom
hyperplastichyperplastic tissue according to mucosal patterntissue according to mucosal pattern
((KudoKudo classification).classification).

IntroductionIntroduction
nn Chromoendoscopy developed in Japan in the 1970Chromoendoscopy developed in Japan in the 1970’’s .s .
nn Chromoendoscopy uses chemical compounds asChromoendoscopy uses chemical compounds as
stains or contrast agents to high lightstains or contrast agents to high light subbtesubbte mucosalmucosal
surface changes or Abnormal gastrointestinalsurface changes or Abnormal gastrointestinal
epithelium.epithelium.
(H.(H. HitookaHitooka, Japan, 2000)., Japan, 2000).
nn Endoscopic tattooing is a different technique where aEndoscopic tattooing is a different technique where a
specific sight in the GIT is labeled by an intramuralspecific sight in the GIT is labeled by an intramural
injection of a carbon ink suspension solution forinjection of a carbon ink suspension solution for
future surgical or endoscopesfuture surgical or endoscopes indentificationindentification..
(Acosta MM, et al., 1998).(Acosta MM, et al., 1998).

Introduction (contIntroduction (cont’’d)d)
nn PronasePronase (antifoam agent)(antifoam agent) premedicationpremedication, significantly, significantly
shortenesshortenes the time forthe time for chromendoscopychromendoscopy and alsoand also
allows for better visualization.allows for better visualization. ((FujiiFujii T, et al., 1998).T, et al., 1998).
nn There are three basic types (methods) ofThere are three basic types (methods) of
chromoendoscopychromoendoscopy
nn Contrast methodContrast method
nn Staining methodStaining method
nn Reaction methodReaction method
nn Several dyes can be used in chromoendoscopy all ofSeveral dyes can be used in chromoendoscopy all of
which are safe, very poorly absorbed from the GITwhich are safe, very poorly absorbed from the GIT
and do not permanently stain the mucosa.and do not permanently stain the mucosa. (H.(H.
MitookaMitooka, 2000)., 2000).

Short Summary on Types ofShort Summary on Types of
ChromoendoscopyChromoendoscopy
Dyes
Blue Others
•Contrast & staining methods
•Indigo Carmine & Meth.blue
•GIT morphology
•Reaction method
•Lugol & Congo red
•GIT secretory functions

Narrow Band Imaging (NBI)Narrow Band Imaging (NBI)
nn Based on the fact that light penetration is wave lengthBased on the fact that light penetration is wave length
dependant; the shorter the WL the shallower the penetration.dependant; the shorter the WL the shallower the penetration.
nn NBI system consists of a filter with narrow band passNBI system consists of a filter with narrow band pass--
ranges, increased blue light (WL 437nm) & decreased red lightranges, increased blue light (WL 437nm) & decreased red light
(WL 630 nm) contribution.(WL 630 nm) contribution.
nn Real time endoscopic technique that enhances visibility ofReal time endoscopic technique that enhances visibility of
mucosal surface structures without use dye ( mucosal pattern ).mucosal surface structures without use dye ( mucosal pattern ).
Endoscopy, 2003Endoscopy, 2003

nn Integrated system with HRE mode & possibility ofIntegrated system with HRE mode & possibility of
switching between both modes.switching between both modes.
nn Few studies performed in comparison toFew studies performed in comparison to
conventional endoscopy in BE, showing betterconventional endoscopy in BE, showing better
IntestinalIntestinal metaplasiametaplasia & HGD detection with NBI& HGD detection with NBI
system.system.
NBINBI

COLONICCOLONIC
POLYPOSISPOLYPOSIS
HOSSAM GHONEIMHOSSAM GHONEIM

Colorectal Polyps
n Definition:
n The term "polyp" refers to any circumscribed mucosal
growth, either flat, depressed, sessile or pedunculated,
that is visible through an endoscope, a magnifying
glass or a stereo-microscope.
n From the Greek:
n polys: many
n pous: the foot
n Many footed

ClassificationClassification
nn NeoplasticNeoplastic (malignant or benign)(malignant or benign)
nn AdenomasAdenomas
nn HistopathologicalHistopathological classificationclassification (Tubular, Villous,(Tubular, Villous,
TubulovillousTubulovillous, Serrated), Serrated)
nn Endoscopic classificationEndoscopic classification ((ExophyticExophytic & Non& Non--exophyticexophytic))
nn Pitt Pattern (Pitt Pattern (KudoKudo’’ss classification)classification)
nn ClinicopathologicalClinicopathological classification (classification ( PolyposisPolyposis syndromes)syndromes)
nn FAP (>100 polyps)FAP (>100 polyps)
nn GardnerGardner (polyps,(polyps, osteomasosteomas,, fibromatosisfibromatosis, keratinous skin cysts), keratinous skin cysts)
nn TurcotsTurcots (I with(I with gliomaglioma, II with, II with medalloblastomamedalloblastoma))
nn Attenuated FAP (< 100 polyps)Attenuated FAP (< 100 polyps)
nn Hereditary flat adenomasHereditary flat adenomas (old age, proximal(old age, proximal ±± gastric Ca, <100 lesions)gastric Ca, <100 lesions)
nn Muir Torre syndromeMuir Torre syndrome (polyps <100 with basal or sq cell carcinoma)(polyps <100 with basal or sq cell carcinoma)
nn Hereditary mixedHereditary mixed polyposispolyposis syndromesyndrome (all + atypical juvenile polyps)(all + atypical juvenile polyps)

nn NeoplasticNeoplastic (cont(cont’’d)d)
nn CarcinomaCarcinoma
nn HNPCCHNPCC
nn LymphomatousLymphomatous polyposispolyposis
nn SubmucosalSubmucosal tumourstumours ( GIST )( GIST )
nn CrcinoidCrcinoid
nn LeomyomaLeomyoma
nn LipomaLipoma
nn SchwannomaSchwannoma

nn NonNon--NeoplasticNeoplastic (not(not tumuruostumuruos))
nn HyperplasticHyperplastic polyp (regenerative /polyp (regenerative / metaplasticmetaplastic))
nn Solitary polypsSolitary polyps
nn MultipleMultiple hyperplastichyperplastic polyposispolyposis syndromesyndrome
nn HamartomasHamartomas (malformation)(malformation)
nn PeutzPeutz--JegerJeger syndromesyndrome (children + brown pig(children + brown pig circumoralcircumoral, hands & feet), hands & feet)
nn JuvenileJuvenile polyposispolyposis (retention polyp(retention polyp-- glands retain secretions)glands retain secretions)
nn Cowden diseaseCowden disease (polyps + facial skin(polyps + facial skin trichilemmomatrichilemmoma))
nn Inflammatory polyps (exaggeratedInflammatory polyps (exaggerated hyperplastichyperplastic))
nn Inflammatory fibroid polyps (Connective tissue overgrowth)Inflammatory fibroid polyps (Connective tissue overgrowth)
nn CronkiteCronkite--CanadaCanada polyposispolyposis syndromesyndrome (sessile diffuse(sessile diffuse polpypspolpyps,,
Alopecia,Alopecia, hyperpigmentationhyperpigmentation & dystrophic nail changes)& dystrophic nail changes)
nn Lymphoid hyperplasiaLymphoid hyperplasia
nn SchistosomalSchistosomal polypspolyps

nn PolypPolyp--like Lesionslike Lesions
nn DALMDALM
nn AntibioticAntibiotic--associated Colitisassociated Colitis
nn Foreign bodiesForeign bodies
nn CondylomaCondyloma acuminatumacuminatum
nn PneumatosisPneumatosis cystoidscystoids intestinalisintestinalis
nn Gas forming bacteriaGas forming bacteria
nn due to mucosal breaks ( e.g. with CD, Drugs,..)due to mucosal breaks ( e.g. with CD, Drugs,..)
nn Fatal in childrenFatal in children

Endoscopic Classification
n Macroscopic
Morphology

KudoKudo’’ss ClassificationClassification

NEOPLASTICNEOPLASTIC
POLYPSPOLYPS

n Pedunculated adenoma
with a long stalk. The
polyp could easily be
resected with a snare.

n Small sessile adenomas of the colon and rectum.

AdenomatousAdenomatous polypspolyps
NONNON--ExophyticExophytic
nn Previously termedPreviously termed ““FlatFlat--AdenomasAdenomas””..
nn Important feature is that highImportant feature is that high--gradegrade dysplasiadysplasia, occurs more, occurs more
frequently than infrequently than in exophyticexophytic adenomas of the same size.adenomas of the same size.
nn NonNon--ExophyticExophytic adenomas that extend superficially over relativelyadenomas that extend superficially over relatively
wide area are calledwide area are called LSTLST (Laterally spreading(Laterally spreading tumourstumours)) oror CreepingCreeping
tumourstumours..
nn IIaIIa ++ IIcIIc,, IIcIIc && IIcIIc ++ IaIa are more frequently associated with highare more frequently associated with high
gradegrade dysplasiadysplasia and carcinoma.and carcinoma.
nn However, carcinoma can start de novo (without identifiableHowever, carcinoma can start de novo (without identifiable
adenoma).adenoma).
nn It is subject of study whether cancer originate from very smallIt is subject of study whether cancer originate from very small
HGD adenomas which are rapidly replaced by expandingHGD adenomas which are rapidly replaced by expanding
malignancy, OR are they just simple adenomas.malignancy, OR are they just simple adenomas.

n Flat adenoma remnant from incomplete
mucosectomy. Observe the scar at the
periphery.

n A large sessile villous adenoma.
n Hardly noticed small depressed adenoma. After
indigo carmine spraying the depressed area is
clearly seen.

n Moderate size sessile adenoma. A small white-
colored hyperplastic polyp is seen at the left
side of the polyp.

n A small exophytic lesion in
the ascending colon with a
contiguous area showing a
decreased vascular pattern
(upper left). After dye
spraying a non exophytic
well circumscribed lesion
was detected beside the small
polyp. The histology report
confirmed adenoma in the
small non-exophytic polyp
while the exophytic lesion
was diagnosed as metaplastic
(hyperplastic).

FamilialFamilial AdenomatousAdenomatous PolyposisPolyposis
(FAP(FAP))
nn DefinitionDefinition
nn An inherited dominant not sexAn inherited dominant not sex--linked syndrome manifested bylinked syndrome manifested by
outgrowth of multiple (up to thousands) colorectal adenomas thatoutgrowth of multiple (up to thousands) colorectal adenomas that ifif
untreated develop into colorectal cancer.untreated develop into colorectal cancer.
nn IncidenceIncidence
nn Rare.Rare.
nn EtiologyEtiology and pathogenesisand pathogenesis
nn Deletion inDeletion in AdenomatousAdenomatous polyposispolyposis Coli (APC) gene on chromosomeColi (APC) gene on chromosome
5.5.
nn Clinical presentationClinical presentation
nn Multiple colorectal adenomas appearing in the second and thirdMultiple colorectal adenomas appearing in the second and third
decades (usually asymptomatic stage).decades (usually asymptomatic stage).
nn Malignant transformation in 100% by age 40, with changes in boweMalignant transformation in 100% by age 40, with changes in bowell
habits, abdominal pain and passage of blood per rectum.habits, abdominal pain and passage of blood per rectum.

(FAP(FAP))
nn Endoscopic findingsEndoscopic findings
nn Depending on the stage of disease, multiple polyps that mayDepending on the stage of disease, multiple polyps that may
cover large areas of the colorectal mucosa.cover large areas of the colorectal mucosa.
nn When more than 100 adenomas are present the conditionWhen more than 100 adenomas are present the condition
may be diagnosed as FAP.may be diagnosed as FAP.
nn Multiple nonMultiple non neoplasticneoplastic fundicfundic gland gastric polyps aregland gastric polyps are
frequent in FAP patients.frequent in FAP patients.
nn Duodenal adenomas (frequently of nonDuodenal adenomas (frequently of non--exophyticexophytic type) withtype) with
predominance for thepredominance for the periampullaryperiampullary region are present in theregion are present in the
majority of patients.majority of patients.
nn TreatmentTreatment
nn ProphylacticProphylactic colectomycolectomy at an early age.at an early age.
nn Periodic endoscopies with multiple biopsies from duodenalPeriodic endoscopies with multiple biopsies from duodenal
adenomas are recommended for cancer surveillance.adenomas are recommended for cancer surveillance.

(FAP(FAP))
nn VariantsVariants
nn Gardner's syndrome:Gardner's syndrome:
nn FAP associated withFAP associated with gastroduodenalgastroduodenal polypspolyps
(inclusive(inclusive periampullaryperiampullary carcinoma) soft tissuecarcinoma) soft tissue
tumorstumors (desmoids,(desmoids, osteomasosteomas,, fibromasfibromas).).
nn Turcot'sTurcot's syndrome:syndrome:
nn FAP associated with brainFAP associated with brain tumorstumors..
nn Attenuated FAP:Attenuated FAP:
nn Late onset with less number of polypsLate onset with less number of polyps
(preferentially right(preferentially right--sided) but with a stillsided) but with a still
significant risk of colon cancer.significant risk of colon cancer.

Familial Adenomatous Polyposis
(FAP)
n Multiple small adenomas of the colon better visualized
after indigo carmine spraying.

n Small, non exophytic adenomas can also be seen
in FAP patients.

Hereditary nonHereditary non--polypoidpolypoid ColorectalColorectal
Cancer (Cancer (HNPCC)..LynchHNPCC)..Lynch syndromesyndrome
nn AnAn autosomalautosomal, dominantly inherited disorder characterized, dominantly inherited disorder characterized
by the development of small number of colorectal adenomasby the development of small number of colorectal adenomas
that frequently progress into colorectal cancer preferentiallythat frequently progress into colorectal cancer preferentially
on the right colon.on the right colon.
nn PseudonymsPseudonyms
nn Also referred to as Lynch syndromes I and II.Also referred to as Lynch syndromes I and II.
nn May account at least for 5% of all colorectal cancers.May account at least for 5% of all colorectal cancers.
nn Inherited defect in the DNA mismatch repair system leadingInherited defect in the DNA mismatch repair system leading
toto microsatellitemicrosatellite instability.instability.

Cancer (HNPCC)Cancer (HNPCC)
nn Onset of colorectal cancer before the age 50.Onset of colorectal cancer before the age 50.
nn FirstFirst--degree relatives with history of early onset ofdegree relatives with history of early onset of
colorectal cancer (< 50y) and involving at least twocolorectal cancer (< 50y) and involving at least two
generations.generations.
nn ExtraintestinalExtraintestinal cancers in somecancers in some kindredskindreds (Lynch(Lynch
syndrome II), specially endometrium, ovary and breast.syndrome II), specially endometrium, ovary and breast.
Less often gastric, ovarian, pancreatic and transitionalLess often gastric, ovarian, pancreatic and transitional
cell carcinoma of thecell carcinoma of the ureterureter and renal pelvis.and renal pelvis.
nn Colorectal cancers with rightColorectal cancers with right--side predominance.side predominance.
nn On early stage of disease, small number of polypsOn early stage of disease, small number of polyps
throughout the colon with predominance of the nonthroughout the colon with predominance of the non--
exophyticexophytic type (flat adenomas) for the right colon.type (flat adenomas) for the right colon.

Cancer (HNPCC)Cancer (HNPCC)
nn DiagnosisDiagnosis
nn Onset of CRC before the age 50 in a nonOnset of CRC before the age 50 in a non--FAP patient andFAP patient and fulfillmentfulfillment ofof
the Amsterdam criteria that includes the documented diagnosis ofthe Amsterdam criteria that includes the documented diagnosis of
colorectal cancer in:colorectal cancer in:
nn At least one family member before age 50.At least one family member before age 50.
nn Three or more relatives; one case a firstThree or more relatives; one case a first--degree relative of the other two.degree relative of the other two.
nn At least two generations.At least two generations.
nn ProphylaxisProphylaxis
nn Patients with positive genetic tests (Patients with positive genetic tests (germlinegermline testing of blood DNA ortesting of blood DNA or
somatic testing of tissue) undergo prophylactic subtotalsomatic testing of tissue) undergo prophylactic subtotal colectomycolectomy..
nn ColonoscopicColonoscopic surveillance is the most accepted alternative and can besurveillance is the most accepted alternative and can be
started at 20 years of age.started at 20 years of age.
nn For those with negative genetic testFor those with negative genetic test colonoscopiccolonoscopic surveillance is stillsurveillance is still
indicated as a significant number of individuals presenting adenindicated as a significant number of individuals presenting adenomasomas
or cancers demonstrate no genetic mutations.or cancers demonstrate no genetic mutations.
nn PeriodicPeriodic gynecologicgynecologic examination and others (stomach & UT) should beexamination and others (stomach & UT) should be
done if documented history of cancers at those sites in family mdone if documented history of cancers at those sites in family members.embers.

Hereditary non-polypoid colorectal
cancer (HNPCC)

n Tiny and very discrete
non-exophytic adenomas
of the colon in a case of
HNPCC.

SubmucosalSubmucosal TumorsTumors of the Colonof the Colon
and Rectumand Rectum
nn Defined as nonDefined as non--epithelialepithelial neoplasmsneoplasms originating fromoriginating from
elements beneath the colorectal mucosa (elements beneath the colorectal mucosa (stromastroma).).
nn PseudonymsPseudonyms
nn GastrointestinalGastrointestinal stromalstromal tumorstumors ((GISTGIST).).
nn Less common than adenomas andLess common than adenomas and hyperplastichyperplastic polyps.polyps.
nn Most common typesMost common types
nn LipomaLipoma,, leiomyomaleiomyoma,, SchwannomaSchwannoma ((neurilemmomaneurilemmoma),),
neurofibromaneurofibroma, granular cell, granular cell tumortumor; and their malignant; and their malignant
counterparts.counterparts. CarcinoidCarcinoid..

nn LocationLocation
nn LipomasLipomas predominate in the right colon.predominate in the right colon.
nn CarcinoidCarcinoid tumorstumors show preference for the rectum.show preference for the rectum.
nn Small lesions usually asymptomatic.Small lesions usually asymptomatic.
nn Larger lesions may present with localized pain, partial obstructLarger lesions may present with localized pain, partial obstruction,ion,
palpable mass or as acute or chronic lower GI bleeding.palpable mass or as acute or chronic lower GI bleeding.
nn BroadBroad--based elevations covered with intact mucosa.based elevations covered with intact mucosa.
nn Bridging folds.Bridging folds.
nn LipomasLipomas, the most common lesions, appear as yellow, the most common lesions, appear as yellow--coloredcolored roundround
sessile lesions with smooth surface that feels soft when touchedsessile lesions with smooth surface that feels soft when touched with awith a
closed biopsy forceps (cushion sign).closed biopsy forceps (cushion sign).
nn CarcinoidsCarcinoids are usually small yelloware usually small yellow--coloredcolored lesions with hardlesions with hard
consistency.consistency.

nn Endoscopic findings may be characteristic not requiringEndoscopic findings may be characteristic not requiring
histological confirmation, as in the case ofhistological confirmation, as in the case of lipomaslipomas..
nn In otherIn other tumortumor types the histological diagnosis may betypes the histological diagnosis may be
difficult as biopsies usually do not reach thedifficult as biopsies usually do not reach the submucosasubmucosa..
nn Repeated biopsy at a same point may establish theRepeated biopsy at a same point may establish the
mesenchymalmesenchymal origin.origin.
nn Fine needle aspiration is often helpful butFine needle aspiration is often helpful but cytologiccytologic evidenceevidence
of malignancy can be difficult toof malignancy can be difficult to identifiyidentifiy in smears andin smears and
therefore endoscopic ultrasound is indicated for staging oftherefore endoscopic ultrasound is indicated for staging of
big lesions prior to removal.big lesions prior to removal.
nn Treatment.Treatment.
nn AsymptomaticAsymptomatic lipomaslipomas do not require excision.do not require excision.
nn SmallSmall carcinoidscarcinoids can be excised after submucosal depositioncan be excised after submucosal deposition
of saline.of saline.
nn BigBig tumorstumors should be surgically treated.should be surgically treated.

LipomaLipoma of the colonof the colon
n Lipoma of the colon with a prickly pear
appearance and positive cushion sign.

CarcinoidCarcinoid of Rectumof Rectum
A: Pedunculated polypoid lesion presenting a
mushroom appearance in the rectum
B: A round and shallow erosion
in the center and a marked mucosal bulge at
the edge of polyp
C: A non-structural pit pattern in the center
with elongated
pits at the edge revealed in magnifying
endoscopy.

Colorectal Lymphomatous Polyposis
n A distinctive form of colorectal lymphoma, with
multiple and large nodules with central depression
representing pathologic lymphoid follicles.

NONNON--NEOPLASTICNEOPLASTIC
POLYPSPOLYPS

HyperplasticHyperplastic PolypsPolyps
((MetaplasticMetaplastic polyps)polyps)
nn Small sessile nonSmall sessile non--neoplasticneoplastic elevations withelevations with
predominance in the rectum and at histologypredominance in the rectum and at histology
present a serrated appearance.present a serrated appearance.
nn Up to 70% of adults over 40 years .Up to 70% of adults over 40 years .
nn LocationLocation
nn ExophyticExophytic type:type: more common in rectum andmore common in rectum and
sigmoid colon.sigmoid colon.
nn NonNon--exophyticexophytic type:type: preference for the right colon.preference for the right colon.

nn Unknown.Unknown.
nn Asymptomatic.Asymptomatic.
nn ExophyticExophytic type:type: Small round nodules with aSmall round nodules with a pale surfacepale surface..
nn NonNon--exophyticexophytic type:type: nonnon--protruding areas frequently covered withprotruding areas frequently covered with
mucus or faeces that become well demarcated after dyemucus or faeces that become well demarcated after dye--spraying.spraying.
At high resolution, after dye spraying,At high resolution, after dye spraying, hyperplastichyperplastic polyps show apolyps show a
pit pattern (starpit pattern (star--like) with regularly distributed round crypts.like) with regularly distributed round crypts.
nn Malignant potentialMalignant potential
nn Considered to be very low (<0.05%). Their relation with serratedConsidered to be very low (<0.05%). Their relation with serrated
adenomas is still a matter of study.adenomas is still a matter of study.
nn The natural course of flatThe natural course of flat hyperplastichyperplastic polyps is still unknown.polyps is still unknown.

nn Differential diagnosisDifferential diagnosis
nn Serrated adenomas may present a similarSerrated adenomas may present a similar
endoscopic appearance.endoscopic appearance.
nn No treatment is required for small lesions, but evenNo treatment is required for small lesions, but even
those small lesions may be difficult to differentiatethose small lesions may be difficult to differentiate
from small serrated adenomas.from small serrated adenomas.
nn Flat nonFlat non--exophyticexophytic lesions require multiple biopsieslesions require multiple biopsies
or resection by mucosectomy to exclude theor resection by mucosectomy to exclude the
presence of a serrated adenoma.presence of a serrated adenoma.

n Typical view of a
hyperplastic polyp of the
rectum seen as a small
round protrusion with a
pale surface.
n Small hyperplastic polyp
of the rectum.

Hyperplastic polyp with granular surface

n Flat hyperplastic polyp
with abundant mucous
that attach feces. The
lesion becomes almost
invisible after flushing
with water but is clearly
demarcated with indigo
carmine dye.

Serrated AdenomasSerrated Adenomas
nn A distinct form of colorectalA distinct form of colorectal neoplasianeoplasia wherewhere adenomatousadenomatous glandsglands
have the serrated epithelial arrangement as inhave the serrated epithelial arrangement as in hyperplastichyperplastic polyps.polyps.
nn LocationLocation
nn More common in rectum and sigmoid colon.More common in rectum and sigmoid colon.
nn UnknownUnknown etiologyetiology..
nn It has been suggested that serrated adenomas could be a reflectiIt has been suggested that serrated adenomas could be a reflectionon
of theof the neoplasticneoplastic transformation of a more differentiated cell in thetransformation of a more differentiated cell in the
colonic crypt than the traditional adenomacolonic crypt than the traditional adenoma
nn Small lesions are asymptomatic. Larger lesions may undergoSmall lesions are asymptomatic. Larger lesions may undergo
malignant transformation.malignant transformation.
nn Small serrated adenomas frequently have a similar endoscopicSmall serrated adenomas frequently have a similar endoscopic
appearance as that ofappearance as that of hyperplastichyperplastic polyps.polyps.

Serrated adenomas of the colon and
rectum

JuvenileJuvenile PolyposisPolyposis
nn A syndrome characterized by the occurrence of multipleA syndrome characterized by the occurrence of multiple hamartomashamartomas
in the colon and less frequently in stomach and small intestine.in the colon and less frequently in stomach and small intestine.
nn Very rare.Very rare.
nn Most probably genetically predetermined. Some cases have a clearMost probably genetically predetermined. Some cases have a clear
autosomalautosomal dominant pattern of inheritance.dominant pattern of inheritance.
nn Rectal bleeding, growth retardation usually appears in childhoodRectal bleeding, growth retardation usually appears in childhood..
nn Multiple polyps in colon & rectum that resembleMultiple polyps in colon & rectum that resemble exophyticexophytic adenomas.adenomas.
nn Due to a low but present risk of malignant transformationDue to a low but present risk of malignant transformation
prophylacticprophylactic colectomycolectomy has been proposed for numerous polyps.has been proposed for numerous polyps.
nn ColectomyColectomy may also be necessary to control bleeding.may also be necessary to control bleeding.
nn If few polyps are present, endoscopic polypectomy with followIf few polyps are present, endoscopic polypectomy with follow--up.up.

n Different views of a pedunculated polyp with
small craters. The histological outcome was
compatible with a hamartoma.

n Juvenile polyposis with multiple pedunculated polyps
in the descending colon.

Inflammatory PolypsInflammatory Polyps
n Two tiny inflammatory polyps.

n Inflammatory polyps seen as finger-like
projections.

n Multiple piriform inflammatory polyps.

n Inflammatory polyps with mucosal bridging.

n Inflammatory changes in
a diverticulum with
swollen mucosa, erosions
and an inflammatory
polyp.

POLYPPOLYP--LIKELIKE
LESIONSLESIONS

DysplasiaDysplasia Associated Lesion or MassAssociated Lesion or Mass
(DALM)(DALM)
nn A colorectal lesion detected at endoscopy in mucosa affected byA colorectal lesion detected at endoscopy in mucosa affected by
inflammatory bowel disease that at histology revealsinflammatory bowel disease that at histology reveals premalignantpremalignant
((dysplasticdysplastic) changes.) changes.
nn LocationLocation
nn Colon and rectum.Colon and rectum.
nn The risk of cancer increases with duration and extension of diseThe risk of cancer increases with duration and extension of disease.ase.
nn These lesions are highly associated withThese lesions are highly associated with adenocarcinomaadenocarcinoma..
nn The majority of lesions are asymptomatic and are only detected dThe majority of lesions are asymptomatic and are only detected duringuring
colonoscopiccolonoscopic surveillance.surveillance.
nn PolypPolyp--like lesions, plaques or flat areas with villous changes.like lesions, plaques or flat areas with villous changes.

DysplasiaDysplasia Associated Lesion or MassAssociated Lesion or Mass
(DALM)(DALM)
nn Multiple biopsies should be taken from suspicious areas andMultiple biopsies should be taken from suspicious areas and
from the adjacent mucosa in separated bottles.from the adjacent mucosa in separated bottles.
nn For some investigators DALM only exists when theFor some investigators DALM only exists when the
neoplasticneoplastic lesion is accompanied bylesion is accompanied by dysplasiadysplasia in thein the
surrounding mucosa.surrounding mucosa.
nn NeoplasticNeoplastic noninvasivenoninvasive lesions withoutlesions without dysplasiadysplasia in thein the
surrounding mucosa are simply diagnosed as adenomas.surrounding mucosa are simply diagnosed as adenomas.
nn Small and isolated lesions withoutSmall and isolated lesions without dysplasiadysplasia in adjacent orin adjacent or
distal segments of flat mucosa can bedistal segments of flat mucosa can be resectedresected
endoscopicallyendoscopically..
nn For widespread lesions occupying large areas or lesionsFor widespread lesions occupying large areas or lesions
associated withassociated with dysplasiadysplasia in adjacent or distal segmentsin adjacent or distal segments
proctocolectomyproctocolectomy is recommended.is recommended.

Condyloma Acuminatum
n Early condyloma
acuminatum of the
anal canal seen as
multiple small white
convex projections
that become
confluent.

Melanosis coli
n A brown mucosal
pigmentation resulting
from chronic laxative
use.
n Multiple lymph follicles,
appearing as white
round spots, contrast
with the surrounding
brown-colored mucosa.

n Mild form of antibiotic-associated colitis with
multiple small raised plaques.

How do polypsHow do polyps
become malignant ?become malignant ?

n Colorectal adenomas are classically defined as
intramucosal neoplasias not extending into the
muscularis mucosae.
n Colorectal cancer is classically defined as a neoplasia
extending beyond the muscularis mucosae.

Adenoma-carcinoma Sequence
n Time perspective.
n The development of a colonic adenoma from normal
epithelium can take about 10-20 years.
n The development of carcinoma from an adenoma may
take as little as two years and as much as thirty years.

Which polyps canWhich polyps can
become malignant ?become malignant ?

Determinants of Malignant
Transformation
n Polyp size.
n The bigger the adenoma, the higher the risk of malignancy.
n Exophytic adenomas under 1 cm very seldom harbor cancer
while lesions over 2 cm in up to 50% of cases harbor cancer.
n The amount of villous component.
n The malignancy rate for tubular adenomas is low while in
villous adenomas up to 30-40%.
n Small adenomas are usually of tubular type. As they grow so
increases the villous component.
n The grading of dysplasia.
n The malignant potential of adenomas increases with increasing
degrees of dysplasia. The grade of dysplasia is directly related to
size and villous component.

nn PolyposisPolyposis syndromessyndromes
nn are at an increased risk of malignant transformation, e.g. 100%are at an increased risk of malignant transformation, e.g. 100%
in FAP.in FAP.
nn Round figure of malignant transformation in all adenomasRound figure of malignant transformation in all adenomas
isis ±± 5 %.5 %.
nn NonNon-- neoplasticneoplastic polypspolyps
nn E.g.E.g. hyperplastichyperplastic (especially if solitary), Juvenile,(especially if solitary), Juvenile, PeutzPeutz--jegerjeger
have a negligible rate of malignant transformationhave a negligible rate of malignant transformation..

Colon preparationColon preparation
nn FermantableFermantable sugars (assugars (as mannitolmannitol) are osmotic) are osmotic
good cleansing agents but carry the potential riskgood cleansing agents but carry the potential risk
ofof ““intracolonicintracolonic explosionexplosion””..
nn COCO22 insufflationinsufflation was previously used to preventwas previously used to prevent
sparkspark--induced explosions. Also, it was absorbedinduced explosions. Also, it was absorbed
much quicker from the colon thus preventing postmuch quicker from the colon thus preventing post
colonoscopy cramps & distension.colonoscopy cramps & distension.

Cold Biopsy Polypectomy
n For small sessile polyps < 5 mm.
n Bleeding is insignificant & will stop spontaneously
(usually small capillary bleeding).

Hot Biopsy Polypectomy
n A small polyp is grasped and
pulled with the biopsy forceps
and thereafter electrocautery is
applied. The base then becomes
white.
n Suitable for polyps <5mm.

Cold Snare Polypectomy
n For small sessile polyps < 6-7mm.
n Bleeding is insignificant & will stop spontaneously
(usually small capillary bleeding).

Basic polypectomy techniqueBasic polypectomy technique

Piecemeal Polypectomy
n The base of a large sessile
adenoma is infiltrated with
1:10000 adrenaline in
hypertonic saline and snare
polypectomy is performed
thereafter.
n The remaining adenomatous
area is subsequently excised
with the snare.
n The ulceration was closed by
placing four metal clips.

APC for polypectomyAPC for polypectomy

Metal clips for polypectomyMetal clips for polypectomy

Tips for difficult polypectomyTips for difficult polypectomy
nn Polyp positionPolyp position
nn It is considerably easier to snare polyps in the "six o'clock poIt is considerably easier to snare polyps in the "six o'clock position"sition"
because the snare enters the field roughly at this orientation.because the snare enters the field roughly at this orientation. Since theSince the
optical element is located above the working channel of the endooptical element is located above the working channel of the endoscope,scope,
attempting to capture polyps at other orientations may result inattempting to capture polyps at other orientations may result in losinglosing
the visual field against a fold prior to capture of the polyp.the visual field against a fold prior to capture of the polyp.
nn It is easier to remove a polyp duringIt is easier to remove a polyp during colonoscoepecolonoscoepe withdrawal as thewithdrawal as the
loops are removed, because both torque and tip deflection are moloops are removed, because both torque and tip deflection are morere
responsive when theresponsive when the colonoscopecolonoscope is straightened.is straightened.
nn Placement of the snare is often facilitated by advancing proximaPlacement of the snare is often facilitated by advancing proximal to thel to the
lesion, deploying the snare, and dragging it over the polyp.lesion, deploying the snare, and dragging it over the polyp.
nn Changing patient's position is helpful for polyps that become suChanging patient's position is helpful for polyps that become submergedbmerged
in a pool of fluid, or long stalkin a pool of fluid, or long stalk--polyps can change direction.polyps can change direction.

nn Access ProblemsAccess Problems
nn Areas where access problems occur commonly are onAreas where access problems occur commonly are on
the medial wall of the cecum, just proximal to thethe medial wall of the cecum, just proximal to the
ileocecalileocecal valve, and on the proximal sides of folds,valve, and on the proximal sides of folds,
flexures, and turns. Large sessile polyps located on theflexures, and turns. Large sessile polyps located on the
proximal side of sharp sigmoid bends can beproximal side of sharp sigmoid bends can be
problematic.problematic.
nn The easiest solution is to remove the polyp inThe easiest solution is to remove the polyp in
retroflexionretroflexion, using an upper GI endoscope (in lt. colon), using an upper GI endoscope (in lt. colon)
oror paediatricpaediatric colonoscopecolonoscope (in rt. Colon).(in rt. Colon).

nn Flat PolypsFlat Polyps
nn Although large flat polyps can be fulgurated with a bipolarAlthough large flat polyps can be fulgurated with a bipolar
probe, laser, or APC, many of these lesions can be removedprobe, laser, or APC, many of these lesions can be removed
with conventional snares.with conventional snares.
nn One technique is to position the snare around the lesion andOne technique is to position the snare around the lesion and
aspirate air from the colon. This will collapse the distendedaspirate air from the colon. This will collapse the distended
colon, and the polyp often moves into the snare, then graspcolon, and the polyp often moves into the snare, then grasp
&& resectresect..
nn Alternatively, the polyp can be lifted with submucosalAlternatively, the polyp can be lifted with submucosal
injection of fluid. However, care must be taken to avoidinjection of fluid. However, care must be taken to avoid
excessive fluid injection; it is not harmful, but it can flattenexcessive fluid injection; it is not harmful, but it can flatten
the polyp even further, making it difficult to capture with athe polyp even further, making it difficult to capture with a
conventional snare loop.conventional snare loop.

nn SnaresSnares
nn A standard polypectomy snare (25A standard polypectomy snare (25--30 mm in diameter or 3 x30 mm in diameter or 3 x
6 cm) may be difficult to use in locations where there is6 cm) may be difficult to use in locations where there is
insufficient working room to fully open the snare. A miniinsufficient working room to fully open the snare. A mini--
snare (12.5snare (12.5--20 mm diameter or 1.5 x 3 cm) can help, which20 mm diameter or 1.5 x 3 cm) can help, which
will usually open fully, even in restricted areas.will usually open fully, even in restricted areas.
nn Tips to fully open a snare:Tips to fully open a snare:
nn Impact the tip of the snare on the opposite wall to facilitate lImpact the tip of the snare on the opposite wall to facilitate lateralateral
separation of the wires.separation of the wires.
nn A needleA needle--tip snare can be used to impact just above (proximal to) thetip snare can be used to impact just above (proximal to) the
polyp, which serves to anchor the snare, and subsequent deploymepolyp, which serves to anchor the snare, and subsequent deploymentnt
of the snare will force the loop to open.of the snare will force the loop to open.

nn Submucosal Injection PolypectomySubmucosal Injection Polypectomy
nn Facilitates safer and easier removal of sessile polyps. fluidFacilitates safer and easier removal of sessile polyps. fluid
lifts the polyp and increases the distance between the base oflifts the polyp and increases the distance between the base of
the polyp and thethe polyp and the muscularismuscularis propriapropria and serosa.and serosa.
nn Most commonly used fluid is normal saline with or withoutMost commonly used fluid is normal saline with or without
epinephrine. This fluid will be reabsorbed; thus, other fluidsepinephrine. This fluid will be reabsorbed; thus, other fluids
have been used in an attempt to prolong the effect, includinghave been used in an attempt to prolong the effect, including
10% glycerol/5% fructose, 50% dextrose, sodium10% glycerol/5% fructose, 50% dextrose, sodium
hyaluronatehyaluronate, and, and hydroxypropylhydroxypropyl methylcellulose.methylcellulose. MB may beMB may be
added to show even distribution of cushion.added to show even distribution of cushion.
nn Fluid is injected using a standardFluid is injected using a standard sclerotherapysclerotherapy needleneedle
placed into theplaced into the submucosasubmucosa at the edge of a polyp, or if theat the edge of a polyp, or if the
polyp is large and flat, multiple injections may be givenpolyp is large and flat, multiple injections may be given
around the periphery. The desired elevation may require 3around the periphery. The desired elevation may require 3--44
mLmL of saline, although larger volumes can be injected safely.of saline, although larger volumes can be injected safely.

nn Inject the proximal (far) aspect of the polyp first. If the distInject the proximal (far) aspect of the polyp first. If the distal aspectal aspect
(closest to the endoscope, and the most tempting) is injected fi(closest to the endoscope, and the most tempting) is injected first, therst, the
polyp can be tilted away from thepolyp can be tilted away from the colonoscopecolonoscope, making resection more, making resection more
difficult. If a bleb does not immediately form, slowly withdrawdifficult. If a bleb does not immediately form, slowly withdraw and liftand lift
the needle slightly while injecting until bleb formation is obsethe needle slightly while injecting until bleb formation is observed. It isrved. It is
often helpful to inject at the lateral margin of the cushion prooften helpful to inject at the lateral margin of the cushion produced byduced by
the previous injection (which has already separated the mucosalthe previous injection (which has already separated the mucosal layerlayer
from thefrom the muscularismuscularis propriapropria).).

nn Rotate to 6 oRotate to 6 o’’clock positionclock position ±±
change patient position.change patient position.
nn InjectInject submucosalysubmucosaly ((coecalcoecal toto
anal).anal).
nn Snare & cut.Snare & cut.

nn If a bleb does not form, the needle may have penetrated theIf a bleb does not form, the needle may have penetrated the
colon wall, or the failure to lift may indicate the presence ofcolon wall, or the failure to lift may indicate the presence of
invasive cancer that is tethering the polyp to the underlyinginvasive cancer that is tethering the polyp to the underlying
muscularismuscularis propriapropria; or previous biopsying. This is called the; or previous biopsying. This is called the
""nonliftingnonlifting signsign”” oror ““desmoplasticdesmoplastic reactionreaction””..
Flat-depressed early colon cancer
about 10mm in diameter. The
lesion had a borderline size
between an indication and no
indication of EMR. Possibility of
desmoplastic reaction (non-
lifting).

nn EMR basic factsEMR basic facts
n Flat lesions up to 20 mm in diameter can relatively easily be
removed by EMR. Larger lesions can be removed piecemeal
but the risk of haemorrhage and perforation increases.
n Before resection the margins of the colonic lesion is determined
by dye spraying.
n Before resection the margins of the colonic lesion is determined
by dye spraying.
n “Grasp and pull" technique is not commonly used for colonic
EMR.
n "Cup and Suction cap" technique has proved less successful for
colonic EMR, because the colonoscope has to be withdrawn
from where the lesion was found for the cap to be fitted, also
risk of perforation was found higher.

nn APC after EMRAPC after EMR
nn The goal should be toThe goal should be to resectresect all of the polyp on the first attempt,all of the polyp on the first attempt,
regardless of size, and to ablate any residual flat disease thatregardless of size, and to ablate any residual flat disease that cannot becannot be
resectedresected..
nn NoNo RCTRCT’’ss have compared ablation tools but most experts currentlyhave compared ablation tools but most experts currently
favor the argon plasma coagulator.favor the argon plasma coagulator.
nn Power settings should be 40 watts in thePower settings should be 40 watts in the coecumcoecum, up to 45 watts in the, up to 45 watts in the
right and transverse colon, and can increase progressively in thright and transverse colon, and can increase progressively in the distale distal
colon, and as much as 60 to 65 watts in the distal rectum.colon, and as much as 60 to 65 watts in the distal rectum.
nn Treatment of residual polyp tissue at the base and rim of theTreatment of residual polyp tissue at the base and rim of the
polypectomy site with APC at the time of initialpolypectomy site with APC at the time of initial
polypectomy may decrease recurrence rate.polypectomy may decrease recurrence rate.

nn FollowFollow--upup
nn Current guidelines recommend that the polypectomy site ofCurrent guidelines recommend that the polypectomy site of
sessile polyps > 2 cm should be reevaluated in 3sessile polyps > 2 cm should be reevaluated in 3--6 months,6 months,
given the tendency for recurrence.given the tendency for recurrence.
nn LargeLarge pedunculatedpedunculated polyps with highpolyps with high--gradegrade dysplasiadysplasia,,
provided theprovided the endoscopistendoscopist is sure there has been completeis sure there has been complete
resection, can undergo their first followresection, can undergo their first follow--up in three years.up in three years.
nn Unless the lesion is in the cecum or rectum, repeatUnless the lesion is in the cecum or rectum, repeat
localization may be problematic, in which case the colon canlocalization may be problematic, in which case the colon can
bebe endoscopicallyendoscopically tattooed.tattooed.

Patients on aspirin or antiplatletes?Patients on aspirin or antiplatletes?
nn Patients taking aspirin for primary prophylaxisPatients taking aspirin for primary prophylaxis
(self(self--prescribed), stop aspirin 7prescribed), stop aspirin 7--10 days before the procedure and10 days before the procedure and
keep off aspirin for up to two weeks after the procedure ifkeep off aspirin for up to two weeks after the procedure if
electrocauteryelectrocautery used.used.
nn If patients are on aspirin with strong indications for preventioIf patients are on aspirin with strong indications for prevention ofn of
cardiovascular orcardiovascular or neurologicneurologic events, do not discontinue the aspirin.events, do not discontinue the aspirin.
nn Absolute risk of bleeding from polypectomy burns, in patients onAbsolute risk of bleeding from polypectomy burns, in patients on
aspirin only, is very low.aspirin only, is very low.
nn Patients taking both aspirin andPatients taking both aspirin and PlavixPlavix have a highhave a high rskrsk of bleeding.of bleeding.
DiscontinueDiscontinue plavixplavix for 5 days before procedure.for 5 days before procedure.

nn For patients onFor patients on WarfarinWarfarin
nn Low risk forLow risk for thromboembolismthromboembolism ((atrialatrial fibrillation without leftfibrillation without left atrialatrial dilation, DVT afterdilation, DVT after
six months of therapy),six months of therapy), acceptable to discontinueacceptable to discontinue warfarinwarfarin 3 to 5 days prior to3 to 5 days prior to
colonoscopy and to resume it following the colonoscopy or aftercolonoscopy and to resume it following the colonoscopy or after some delay ifsome delay if
there appears to be a substantial risk of bleeding.there appears to be a substantial risk of bleeding.
nn High riskHigh risk (e.g.(e.g. atrialatrial fibrillation with MV disease and leftfibrillation with MV disease and left atrialatrial dilation, prostheticdilation, prosthetic mitralmitral
valves),valves), acceptable to discontinueacceptable to discontinue warfarinwarfarin and continueand continue LovenoxLovenox as anas an
outpatient, giving the last dose 24 hours prior to the procedureoutpatient, giving the last dose 24 hours prior to the procedure. Both. Both LovenoxLovenox
andand warfarinwarfarin can then be restarted on the evening of the procedure.can then be restarted on the evening of the procedure.
nn LovenoxLovenox is expensive, alternatively, discontinuation ofis expensive, alternatively, discontinuation of warfarinwarfarin, followed by, followed by
hospitalization and intravenoushospitalization and intravenous heparinizationheparinization after the INR drops. In this case,after the INR drops. In this case,
IV heparin is discontinued 4 hours prior to the colonoscopy andIV heparin is discontinued 4 hours prior to the colonoscopy and restarted 4 to 6restarted 4 to 6
hours afterwards.hours afterwards.
nn Whenever patients are to be reWhenever patients are to be re--anticoagulatedanticoagulated, consideration should be given to, consideration should be given to
clipping the polypectomy site.clipping the polypectomy site.
ASGE Guidelines, 2004ASGE Guidelines, 2004

Should everyShould every endoscopistendoscopist attempt toattempt to
removeremove everyevery polyp?polyp?
nn This is probably the wrong message to send. Large polypsThis is probably the wrong message to send. Large polyps
are in fact associated with a higher rate of complications.are in fact associated with a higher rate of complications.
Some polyps will require surgical removal, but the bestSome polyps will require surgical removal, but the best
gauge of whether a givengauge of whether a given endoscopistendoscopist should attemptshould attempt
removal is the degree of experience and level of comfort ofremoval is the degree of experience and level of comfort of
thatthat endoscopistendoscopist..
nn However, one should not assume that because one's ownHowever, one should not assume that because one's own
level of comfort is exceeded, that this necessarily mandateslevel of comfort is exceeded, that this necessarily mandates
surgery; in such cases, thesurgery; in such cases, the endoscopistendoscopist should be willing toshould be willing to
consult with a more experienced colleague or considerconsult with a more experienced colleague or consider
referring the patient to another center.referring the patient to another center.

Which Polyps Should Be Treated InitiallyWhich Polyps Should Be Treated Initially
With Surgical Resection?With Surgical Resection?
nn Generally accepted criteria for large sessile polypsGenerally accepted criteria for large sessile polyps
that should be referred for surgical removalthat should be referred for surgical removal
nn (1) polyps that laterally encompass more than one(1) polyps that laterally encompass more than one
third of the bowel circumference;third of the bowel circumference;
nn (2) those that extend longitudinally over 2(2) those that extend longitudinally over 2
successivesuccessive haustralhaustral folds;folds;
nn (3) lesions that grossly appear to be malignant ((3) lesions that grossly appear to be malignant (egeg,,
irregular, friable, firm/hard, ulcerated, bleeding);irregular, friable, firm/hard, ulcerated, bleeding);
nn (4) polyps that extend into the appendix, a(4) polyps that extend into the appendix, a
diverticulum, or thediverticulum, or the ileocecalileocecal valve, or otherwisevalve, or otherwise
wrap around a sharp fold.wrap around a sharp fold.

Complications of polypectomyComplications of polypectomy
nn Immediate bleedingImmediate bleeding
nn APCAPC
nn Metal clipMetal clip
nn Delayed bleedingDelayed bleeding
nn Few hrs to 12 daysFew hrs to 12 days
nn Occurs in about 2% of casesOccurs in about 2% of cases
nn Emergency colonoscopy neededEmergency colonoscopy needed
if ongoing bleeding. Slowif ongoing bleeding. Slow
tapering bleeding will stoptapering bleeding will stop
spontaneously.spontaneously.

nn PerforationPerforation
nn 0.040.04--2.1%2.1%
nn Manifests within few hoursManifests within few hours
nn Clinical presentation is a must (pain), if intra orClinical presentation is a must (pain), if intra or
retroperitoneal air is present, treatretroperitoneal air is present, treat
nn NPO, Antibiotics, and observationNPO, Antibiotics, and observation
nn No clinical presentation but air in imaging =No clinical presentation but air in imaging = ““benignbenign
pneumoperitoneumpneumoperitoneum””, occurs in 1% of colonoscopies, occurs in 1% of colonoscopies
(without intervention). Self(without intervention). Self--limiting.limiting.
nn Large evident perforation (seeingLarge evident perforation (seeing serosalserosal surface of othersurface of other
organs) warrants immediate surgical exploration.organs) warrants immediate surgical exploration.

nn Post polypectomy syndromePost polypectomy syndrome
nn TransmuralTransmural burn causing irritation of serosa with aburn causing irritation of serosa with a
localized inflammatory response.localized inflammatory response.
nn Localized pain, tenderness, guarding & rigidity in the areaLocalized pain, tenderness, guarding & rigidity in the area
overlying the polypectomy site;overlying the polypectomy site; ±± fever, tachycardia orfever, tachycardia or
leukocytosis.leukocytosis.
nn Occurs 6hrs to 5 days after 1 % ofOccurs 6hrs to 5 days after 1 % of polypectomiespolypectomies..
nn Usually selfUsually self--limiting in about 2limiting in about 2--5 days; otherwise antibiotics,5 days; otherwise antibiotics,
IV fluids & observation will be enough.IV fluids & observation will be enough.
nn D.D. perforation. Radiographic air present with perforation,D.D. perforation. Radiographic air present with perforation,
absent withabsent with postpolypectomypostpolypectomy syndrome.syndrome.

Take home messageTake home message
nn Careful patient evaluation & clinical examination.Careful patient evaluation & clinical examination.
nn Meticulous colonoscopy for minute or flat lesionsMeticulous colonoscopy for minute or flat lesions
nn Tip: watch for abrupt discontinuity of vascular pattern & considTip: watch for abrupt discontinuity of vascular pattern & considerer chromoscopychromoscopy..
nn Perform upper GI endoscopy when SuspiciousPerform upper GI endoscopy when Suspicious
nn E.g. in FAP & FAP variantsE.g. in FAP & FAP variants
nn Which polyps become malignant?Which polyps become malignant?
nn Biopsy & follow report.Biopsy & follow report.
nn KudoKudo’’ss classification.classification.
nn GISTsGISTs can becan be biopsiedbiopsied but do NOT attempt polypectomy.but do NOT attempt polypectomy.
nn Cushion sign ofCushion sign of lipomalipoma (yellow & soft)(yellow & soft)
nn Hard consistency ofHard consistency of CarcinoidCarcinoid (yellow & hard)(yellow & hard)
nn DALM can be removedDALM can be removed endoscopicallyendoscopically if adjacent mucosa is free ofif adjacent mucosa is free of dysplasiadysplasia..

nn PolypectomyPolypectomy
nn Position of polypPosition of polyp
nn Position of patientPosition of patient
nn Size of snareSize of snare
nn Submucosal injectionSubmucosal injection
nn APC & metal clips prophylaxis & for complicationsAPC & metal clips prophylaxis & for complications
nn AnticoagulatedAnticoagulated patientspatients
nn Follow up after polypectomyFollow up after polypectomy
nn When to send for surgeryWhen to send for surgery
nn 1/3 of bowel circumference1/3 of bowel circumference
nn 2 successive2 successive haustralhaustral foldsfolds
nn Grossly malignant lesionsGrossly malignant lesions
nn Polyp in diverticulum,Polyp in diverticulum, ileocoecalileocoecal valve, etc.valve, etc.

Colonic polyposis

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Colonic polyposis

Similar to Colonic polyposis (20)

More from Hossam Ghoneim

More from Hossam Ghoneim (20)

Recently uploaded

Recently uploaded (20)

Colonic polyposis