BACKGROUND & AIMS: Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use. METHODS: An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding <= 30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders. RESULTS: Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps >= 20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35-0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16-1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps >= 20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79-2.52). CONCLUSIONS: Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps >= 20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping.

Background Endoscopic mucosal resection (EMR) is a minimally invasive procedure used for the treatment of lesions in the gastrointestinal (GI) tract. There is increased usage of hemoclips during EMR for the prevention of delayed bleeding. This study aimed to evaluate the effect of hemoclips in the prevention of delayed bleeding after EMR of upper and lower GI tract lesions. Method This is a retrospective cohort study using the Kaiser Permanente Southern California (KPSC) EMR registry. Lesions in upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were analyzed. Rates of delayed bleeding were compared between the hemoclip and no-hemoclip groups. Analysis was stratified by upper GI and lower GI lesions. Lower GI group was further stratified by right and left colon. We examined the relationship between clip use and several clinically-relevant variables among the patients who exhibited delayed bleeding. Furthermore, we explored possible procedure-level and endoscopist-level characteristics that may be associated with clip usage. Results A total of 18 out of 657 lesions (2.7%) resulted in delayed bleeding: 7 (1.1%) in hemoclip group and 11 (1.7%) in no-hemoclip group ( p = 0.204). There was no evidence that clip use moderated the effects of the lesion size ( p = 0.954) or lesion location ( p = 0.997) on the likelihood of delayed bleed. In the lower GI subgroup, clip application did not alter the effect of polyp location (right versus left colon) on the likelihood of delayed bleed ( p = 0.951). Logistic regression analyses showed that the clip use did not modify the likelihood of delayed bleeding as related to the following variables: use of aspirin/NSAIDs/anti-coagulants/anti-platelets, pathologic diagnoses (including different types of colon polypoid lesions), ablation, piecemeal resection. The total number of clips used was 901 at a minimum additional cost of $173,893. Conclusion Prophylactic hemoclip application did not reduce delayed post-EMR bleed for upper and lower GI lesions in this retrospective study performed in a large-scale community practice setting. Routine prophylactic hemoclip application during EMR may lead to significantly higher healthcare cost without a clear clinical benefit.

Turmeric is a popular herbal dietary supplement that has been considered safe and even shown to have hepatoprotective properties. In the recent times, however, there have been a few case reports of turmeric-induced liver injury. We report a 55-year-old woman with chronic turmeric consumption whose initial diagnosis was acute autoimmune hepatitis. She declined steroid treatment, and hence, we recommended discontinuing her long-term turmeric usage. A month after discontinuation, her liver function returned to normal. This case demonstrates the importance of recognizing the potential adverse effects of herbal dietary supplement.

Background: Discontinuation of branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) surveillance after 5 years of no change remains controversial. Long-term outcomes of BD-IPMN without significant changes in the first 5 years were evaluated. Methods: We performed a multi-center retrospective analysis of patients with BD-IPMN diagnosis from 2005 to 2011 (follow-up until 2017). Significant changes were defined as pancreatic cancer (PC), pancreatectomy, high-risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). Results: Of 982 patients who had no significant changes, 5 (0.5%), 7 (0.7%), 99 (10.1%), 4 (0.4%) patients developed PC, HRS, WF, WEUS, respectively, post-5 years. PC and HRS/WF/WEUS incidences at 12 years were 1.0% and 29.0%, respectively. Patients that developed HRS/WF/WEUS had larger cyst size in first 5 years compared to those that did not [16 (12-23) vs. 12 (9-17) mm, p = 0.0001], cyst size of >15 mm having higher cumulative incidence of HRS/WF/WEUS. PC mortality was 0.8%; all-cause mortality was 32%. Incidence of mortality due to PC was higher in HRS/WF/WEUS group, p < 0.0001. The mortality rate at 12 years for ACCI (age-adjusted Charlson Comorbidity Index) of <= 3, 4-6, and >= 7 were 3.5%, 19.9%, and 57.6% (p < 0.0001), respectively. Conclusions: Incidence of PC in patients with BD-IPMN without significant changes in first 5 years of diagnosis remains low at 1.0%. Incidence of HRS/WF/WEUS was higher at 29.0%. PC-related mortality was higher in HRS/WF/WEUS group. These risks should be weighed against patients' overall mortality (utilizing scoring systems such as ACCI) when making surveillance decision of BD-IPMN beyond 5 years. (C) 2020 Published by Elsevier B.V. on behalf of IAP and EPC.

ABSTRACT The 2 most common types of amyloidosis are light chain (AL) and reactive (AA). AL is associated with plasma cell dyscrasias; reactive (AA) is associated with chronic inflammatory conditions. A few cases have described AL amyloidosis mimicking colitis. However, endoscopic findings leading to the diagnosis of AL amyloidosis are rare. We report a 77-year-old woman with a medical history of ulcerative colitis who presented with recurrent nonbloody watery diarrhea. Colonoscopy revealed features suspicious for amyloidosis. Bone marrow biopsy showed multiple myeloma and AL amyloidosis. This case demonstrates the importance of generating a broad differential and the pivotal role of endoscopic findings in diagnosing uncommon diseases.

INTRODUCTION: Discontinuation of surveillance after 5 years for pancreatic cystic lesions (PCL) without significant changes remains controversial. Long-term outcomes of patients with PCL with no significant changes in the first 5 years were evaluated. METHODS: We performed a retrospective analysis of patients with PCL diagnosis from 2005 to 2011 with follow-up until 2017. Significant changes were defined as the history of pancreatic cancer, pancreatectomy, high risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). Details of HRS, WF, WEUS in Table 1. RESULTS: Of 1551 patients with the diagnosis of PCL, 984 had no significant changes in the first 5 years. Range of follow-up was 5–13 years (190 patients >10 years). Median (Q1–Q3) cyst size at initial imaging was 12 (9–17) mm; maximum cyst size in first 5 years and post 5 years were 13 (9–18) mm and 15 (10–22) mm, respectively. 4 patients developed pancreatic cancer (0.41%; at 80, 97, 70, and 103 months). 7 (0.71%), 99 (10%), 5 (0.51%) patients developed HRS, WF, WEUS, respectively. Median (Q1–Q3) time to cancer, HRS, WF, and WEUS were 88.7 (75.3–100), 97.2 (66–109.6), 78.2 (72.5–97.9), 77 (68–104) months, respectively. Patients with CSO/clinically significant outcomes (defined as pancreatic cancer, HRS, WF, WEUS) post 5 years had larger maximum cyst size in the first 5 years compared to those without CSO [median (Q1–Q3) 16 (12–23) vs 12 (9–17) mm, P = 0.0001] (Figure 1). 152 patients died post 5 years (3 due to pancreatic cancer). The incidence of pancreatic cancer and CSO at 7 years post 5-year period (12 years from PCL diagnosis) in patients with no significant changes were 0.7% and 12.5%, respectively. The mortality due to pancreatic cancer was 0.45%; mortality due to all causes was 31.7%. Median (range) of Charlson Comorbidity Index (CCI) was 2 (0–16) at 5 years post PCL diagnosis. The mortality rate at 7 years post 5-year period for ACCI (age-adjusted CCI) of ≤3, 4–6, and ≥7 were 3.5%, 28% and 58% ( P < 0.0001), respectively (Figure 2). CONCLUSION: The incidence of pancreatic cancer in patients with PCL with no significant changes in the first 5 years of diagnosis remains low at 0.7%. The incidence of clinically significant outcomes (CSO) was higher at 12.5%. Maximum cyst size of ≥15 mm in the first 5 years had higher cumulative incidence of CSO in long-term follow-up. These risks should be weighed against patients' overall mortality (based on scoring systems such as CCI) when making surveillance decision of PCL beyond 5 years.

Case: A 60 year old Caucasian male with PMH of CABG, HTN, HLD, DM2 came to the ED with chief complaint of 3 weeks of constipation. Plain films revealed ileus. Rectal decompression tube and NG tube were placed; he was given a dose of Neostigmine after failing conservative measures. He improved and was discharged with a diagnosis of Ogilvie's syndrome. However, he came back a month later with the same chief complaint. CT abdomen and pelvis showed a dilated colon up to 9cm with focal narrowing at the rectosigmoid segment. Colonoscopy showed a smooth narrowing 11.5cm from the anal verge. The narrowing revealed normal appearing mucosa with no evidence of inflammation or tumor. This was felt to be due to extrinsic compression and did not respond to dilation. Biopsy of the area was negative for malignancy with benign colonic mucosa. EUS of the rectal narrowing revealed an intact echo-layer pattern of the rectal wall. The submucosal and muscularis propria layer, however, were focally thickened with adjacent lymphadenopathy. FNA of lymph nodes was not performed due to unprepped exam and risk of infection. Further review of the CT scan showed sclerotic lesions on the spine and pelvic bone concerning for metastatic disease. A bone scan showed multiple lesions concerning for malignancy. Urology was consulted; prostate biopsy confirmed prostate adenocarcinoma. CT guided biopsy of the bone lesions, however, were negative for malignancy. A repeat EUS of the rectal narrowing showed persistent focal thickening of the 3rd and 4th layers and resolution of the lymphadenopathy. To obtain a deeper biopsy of the submucosal layer, endoscopic mucosal resection of part of the rectal stricture was performed. Pathology showed metastatic prostate cancer infiltrating the submucosa from the serosal side of the colon wall creating the stricture. Discussion: Prostate cancer is one of the most common causes of cancers in men worldwide with its peak incidence at 60-70 years of age. Most commonly reported symptoms of advanced prostate cancer are fatigue, urinary symptoms, sexual function symptoms and bone pain. Metastatic prostate adenocarcinoma presenting as constipation is rare. This case emphasizes the importance of generating a broad differential, understanding of the anatomy and how a tumor can impair the motility of the colon. We also present this case to report a relatively new application in which EMR achieved the correct diagnosis causing this patient's constipation.