Saudi Journal of Gastroenterology

IMAGE QUIZ
Year
: 2013  |  Volume : 19  |  Issue : 1  |  Page : 54--55

Colonic lacerations, mucosal scars and image enhancement: An on-the-spot diagnosis


Alexandros Smirnidis, Efstratios Alexandridis, Anastasios Koulaouzidis 
 Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Correspondence Address:
Anastasios Koulaouzidis
Centre for Liver and Digestive Disorders, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA
United Kingdom




How to cite this article:
Smirnidis A, Alexandridis E, Koulaouzidis A. Colonic lacerations, mucosal scars and image enhancement: An on-the-spot diagnosis.Saudi J Gastroenterol 2013;19:54-55


How to cite this URL:
Smirnidis A, Alexandridis E, Koulaouzidis A. Colonic lacerations, mucosal scars and image enhancement: An on-the-spot diagnosis. Saudi J Gastroenterol [serial online] 2013 [cited 2021 Oct 16 ];19:54-55
Available from: https://www.saudijgastro.com/text.asp?2013/19/1/54/105929


Full Text

An 84-year-old female was admitted with acute-on-chronic renal failure. She had been complaining of profuse, watery diarrhoea and vomiting for few weeks prior to her admission. She had a previous history of aortic valve replacement and hypothyroidism for which she was on beta-blockers, frusemide, aspirin and levothyroxine. She was also on lansoprazole. Stool microscopy and cultures were negative, whilst the kidney ultrasound and autoimmune profile were unremarkable. Her colonoscopy showed lacerations in the right colon and a longitudinal mucosal fracture with an adjacent cicatricial lesion in the rectum [Figure 1]a. A reticulo-nodular mucosal pattern was also noted with indigo carmine chromoendoscopy [Figure 1]b.

Another 77-year-old female, on long-term lansoprazole and naproxen, was referred for evaluation of increased bowel frequency and abdominal pains. A colonoscopy revealed few cicatricial lesions in the left colon and fresh mucosal lacerations in the ascending colon [Figure 2]a. Furthermore, application of Index of Haemoglobin (IHb) colour enhancement revealed redness of the surrounding mucosa [Figure 2]b.{Figure 1}{Figure 2}

 Questions



Q1. What is the diagnosis?

Q2. What are the suggestive features of this entity on endoscopy and chromoendoscopy?

 View Answer

 Answers



Biopsies revealed a thickened subepithelial collagen table, increase in the intraepithelial lymphocytes and inflammation of the lamina propria, characteristic of collagenous colitis (CC). CC is associated with normal or almost normal colonoscopy and clinically follows a benign course. The concurrent presence of mucosal lacerations and/or fractures in the thin-walled right colon with hypertrophic (celoid type) mucosal scars in the left colon is considered highly suggestive of CC. [1] Moreover, a mosaic or "honeycomb" mucosal pattern with disarranged innominate mucosal grooves, is indicative of CC. It has been shown that chromoendoscopy with indigo carmine accentuates those changes thereby aiding in endoscopic diagnosis of CC. [2],[3]

Index of Haemoglobin (IHb) features an algorithm that increases the redness of mucosa, based on the received R (red) and G (green) signals. Therefore, mucosal areas of increased blood supply are accentuated in red. It is incorporated in the EVIS LUCERA videoscope system (Olympus® Tokyo, Japan) and is applicable for image analysis of endoscopic color and enhancement of the mucosal vascular flow change. [4] Enhancement of mucosal pattern either with indigo carmine chromoendoscopy or IHb application, especially when other colonoscopic findings (mucosal fractures, scars or lacerations) are strongly suggestive of CC, should be considered as a further useful step towards an "on-the-spot" diagnosis and should prompt initiation of therapy without delay. In the first case, budesonide was commenced during a hospital re-admission, as beta-blockers and lansoprazole discontinuation had no effect.

By that time, biopsies had confirmed thickening of the sub-epithelial collagen band and an extensive denudation of the surface epithelium with focal increase of the intraepithelial lymphocytes. The second patient received budesonide immediately post-colonoscopy with remarkable effect.

In conclusion, we recommend that in cases with pathognomonic colonoscopic findings, therapy should be started immediately post-endoscopy, thus avoiding unnecessary delays in patient management.

References

1Koulaouzidis A, Saeed AA. Distinct colonoscopy findings of microscopic colitis: Not so microscopic after all? World J Gastroenterol 2011;17:4157-65.
2Suzuki G, Mellander MR, Suzuki A, Rubio CA, Lambert R, Björk J, et al. Usefulness of colonoscopic examination with indigo carmine in diagnosing microscopic colitis. Endoscopy 2011;43:1100-4.
3Cimmino DG, Mella JM, Pereyra L, Luna PA, Casas G, Caldo I, et al. A colorectal mosaic pattern might be an endoscopic feature of collagenous colitis. J Crohns Colitis 2010;4:139-43.
4Igarashi M, Saitoh Y, Fujii T. Adaptive index of haemoglobin color enhancement for the diagnosis of colorectal disease. Endoscopy 2005;37:386-8.