Video Endoscopy Case Conference 10/2/20 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Case Conference 10/2/20 Overview Two cases are presented here: • 00:07 – Laterally Spreading Tumors • 17:40 – Ischemic Colitis Good morning, everyone. Um Stephanie, Steph squared are going to be presenting this morning. Um, and I'm going to be presenting a case that I saw with Dave two weeks ago. That was a great, very exciting case for me, at least. Um, so I'm presenting a case of a 53 year old woman. She is a past medical history of obesity and osteoarthritis. She presented to her regular doctor for a yearly physical. At that visit, there was documentation that they discussed that she should get a screening colonoscopy. She never had a column before and have a lot of questions. There was concern on her end due to perceived invasiveness of the procedure. She didn't have somebody who could take her home. And so because of that, they proceeded with a cola guard test instead of a colonoscopy. The Cold Guard was positive. And so therefore, she was subsequently referred to G I for a colonoscopy. Just moving this thing on the bottom. Sorry. Okay. Mhm. Yep. So this is who this is the video. Thank you, Nick, by the way, for helping me get this to work last night. Um, so we're doing the colonoscopy and we get to the splenic fleck Sh er and this is what we find this large area of Nagy Alert and some depressed mucosa. There were areas of fry ability where we and then we tried to biopsy. Yeah, these are just three pictures of the area kind of showing that it was depressed in some areas and more raised up above. Um, and again this area extended really pretty extensively at the splenic lecture. We then proceeded to tattoo the adjacent wall so you can see our tattoo here for future procedures, and we biopsied. So I thought I'd take a moment this morning. A lot of many of us were talking about this case and how interesting it was talking about what a laterally spreading tumor is in a little bit more information about it. Um so laterally spreading tumors are considered very important precursors of colorectal cancer. They're defined by the Paris Consensus as a lesion larger than 10 millimeters in width, and it needs to extend both laterally and circumferential e, and not just specifically vertically. You'll often see people discuss whether they're granular or non granular, homogeneous or non homogeneous, heterogeneous, um, and the appearance of the tumor, So we'll talk about that as well, for when we see them on endoscopy so we can grade them appropriately. As we said, they spread laterally and very commonly do not invade into the 70 coastal layer, which makes an endoscopic resection actually the ideal treatment for these tumors and therefore don't need surgical intervention. So I thought this was a nice picture. We had actually pulled it up in endoscopy, but essentially brings up the two different kinds of laterally. Spreading tumors shows that there are the granular and the non granular us, and they can be homogeneous in the way they appear, or they can be heterogeneous flat, and we're actually depressed, depressed or elevated off of the surface. These are some pictures, some other pictures, just as more representative for everyone, granular us and then this non granular so laterally spreading to us. We often talk about endoscopic management very commonly as EMR. I read that you can do and block resection of lesions less than two centimeters, and you can also do piecemeal receptions of larger lesions. Other papers have discussed using SD for management of larger lesions. Those would depress morphology or if there's any concern, of course, for sub mucosal invasion. So I found a Met a systematic review with meta analysis that was done in 2019 looking at how to manage these, um, laterally spreading tumors. So it's just this systematic review looked three different databases and included a total of 49 studies. 27 of them specifically looked at laterally spreading to us, and then 22 of them had as a subset, um, all of them are over 10 millimeters, but they did not break it down by the type, whether they were granular, homogeneous, heterogeneous, etcetera. They looked at the overall pooled, successful reception rate and that was 75.6% and that was broken down. Then subsequently by E. M. R and D S D. And you can see there's pretty significant difference, with EMR being 37% and E S t v 93%. And overall it was considered a curative procedure in 90% of cases which I thought was amazing. And the lowest curate was in one study that was only looking at lesions greater than three centimeters in terms of adverse events. They looked at perforation rates bleeding rates both immediate and delayed. They found that the pooled perforation rate was 4% but not surprisingly higher with VSD compared to EMR. And then the pool bleeding rate was significantly higher in the EMR group, Um, and less than the S D group. They looked at recurrence, um, and they found that it was not surprisingly higher with EMR compared to e s d 5% of patients But 87% of these were successfully treated on a second endoscopic procedure, so they did not need to go to the O. R. And only 2% of the patients in the study actually who had undergone an endoscopic resection ultimately were referred for surgical procedure. And the reasons for these included adverse events, recurrence and then incomplete resection, which was the highest reason. I then found another paper that I thought was interesting out of Australia looking at risk stratification for which of these, um, laterally spreading tumors or highest risk for mucosal invasion. Because when we originally saw this tomb, our first concern was that there was a malignancy in this young woman. So this study had, um, 2017 and out of Australia looked basically at large Cecil Polyps and LSE, so it wasn't specifically looking at laterally spreading tumors but included over 2000 laterally spreading tumors. They found some mucosal invasive cancer in 7.6% of lesions. And these were kind of the criteria that were so most highly associated with the development of a, um, invasive malignancy acuerdo pit pattern, a five depressed component which we had talked about a little bit. Recto sigmoid lesion, specific Paris classification and non granular surface morphology. I liked this paper because they presented this graphic which I thought was very helpful in showing at the top the homogeneous and the second row where the heterogeneous laterally spreading tumors showing that actually the non granular laterally spreading tumor was the highest risk, um, for developing an invasive cancer. And interestingly, they broke them down. Whether or not they were proximal or just still interesting and the granular homogeneous were the lowest risk. Those are the bottoms are obviously not battery. So back to our case, we buy into the lesion. We took care, doctor was very specific to make sure we do not buy to the lateral edges. So we didn't cause any scarring to help with future EMR We tattooed the wall as I showed you, and path came back to to build villas adenoma. And she is planned for m r e s d next week with Satish. So just in quick conclusion, laterally spreading us are these large lesions greater than one centimeter and with explain expand laterally and circumferential e along the Kalanick wall and not vertically e m r and E s d are much less invasive modality for treatment than sending the patients to the operating room. Highly effective, highly curative and majority of patients if you see recurrence after the first endoscopic procedure, that second endoscopic intervention is often successful and a fairly low rate of adverse events Just remember non granular heterogeneous. You are the most highly associated with underlying invasive malignancy, which is what our patient had, and they are screening colonoscopies, save lives. So thank you. Great. That's fantastic. Case and covered covered from a to Z there. Um you know So, Steph, if if you were to attempt, you know, there is that maybe go back to the picture of the original endoscopy. Um, you know, So when you're assessing this. Um, and we've talked about this, You know, a lot at this conference and grand rounds and other things. And, you know, the bottom line is, I think you guys made the smart decision that if you're not, if you're going to do a polyp ectomy removal, um, you need to go in with the intent of completing it. You never want to do a partial polytech to me. You never want to do, um, you never want to start it if you don't think you can stop it. And the question comes up all the time. If you're doing the screening Colon and see one of these, what should you do? And, you know, I think I'm sure I can speak for sufficient Akil, is that you know, when we get called in the room, one of you guys find one of these things Or if we find one of these on a screening Colon, You know, I think our preference is to not tackle it right then and there. Personally, I booked these cases for about 90 minutes. You need to take time. This this is not like a five minute procedure. They don't always. They can certainly just take 20 minutes or so, but you want to be. You want to really have all your equipment therapy, be ready to do things and also counsel the patient pre procedure about the potential risks and everything. So step just point to the group where the smooth, non granular portion is. There appears to be smooth, non granular here. Yeah, and that's exactly right. And what's interesting about this is it's the granular portion. Maybe just point out the granular portion for everybody. It's the granular portion that always scares people in here in the middle of the middle of that lesion. It's the granular portion that always scares people when we get these cases referred in, um, and interestingly, that's usually the most benign portion. The risk of invasive cancer and the granular portion its near zero. Um, fortunately, the smooth or non granular lesions are less common. But, Steph, if you guys were to attempt a resection, what kinds of things would make you stop? Um, as you were going what what what features? Um of the procedure of the pilot would maybe give you pause about whether or not you should continue the reception I mean, if we were to have attempted it that day, I think the depressed components certainly was concerning, because that maybe needs a deeper resection. Um, the fact that in this in this area does it did look so much oppressed us. They were both raised and depressed components. Um, in terms of, I guess, just the size of it. How about maneuver wise? Is there anything you know? Like if you injected it or try to snare? Is there anything that would give you concern If it didn't lift appropriately, you'd be concerned that there was a new proposal, invasion or sub mucosal, right? So that's exactly right. So and I think we all know that the non lifting sign and you can get fooled out by the non lifting sign if extensive biopsies are taken. And again, I think you guys did a perfect job of trying to minimize the risk. If you take too many biopsies or sometimes, you know, we get these referrals from the outside where it's my favorite line, they'll say, you know, there's a 3.5 centimeter polyp, but don't worry. I took out half of it with a snare that's like the worst thing in the world for us because it just creates scar tissue. And you really can't tell if that sub mucosal invasion from cancer for just fibrosis. Um and then the last thing is tattooing. You never want to tattoo inside the lesion. You always want a tattoo away from it, because again that can cause a very severe fiber optic reaction and minimize your success, Um, or making it more. I shouldn't say Minimize yourself, just making it more difficult to respect it. But usually we can get around that, Um, Chris, can I just ask, Was there was there really any point in taking a biopsy at all? Couldn't you argue, no matter what, this had to come out the biopsy. I think it's I think, if you think if you took a biopsy of a very suspicious area and it came back cancer, I think you're done, and then the patient can just go right to surgery. Think that's the point of this. But is there a possibility of bypassing and not finding cancer? And it still is, of course, of course, and that's part of the counseling with the patient before an endoscopic resection is you know, we may tell them, and this happens. Not infrequently. We may completely respect the Legion, but if the pathology comes back showing invasive cancer, you're likely going to need surgery for a definitive oncological section again meaning lymph node dissection. Which is exactly what we did. We took like two biopsies of the most suspicious looking area nowhere near anywhere where you were likely to be injecting underneath to respect it, and figured that we needed to come back and talk to her and set up an extended session to remove this mhm. And then just just one last point I'll make before anyone else has any other thoughts is that you know that those papers you quoted her from Michael Burke from Australia and he, I would argue, and I think Jerry would argue as well is the world's preeminent Palop ectomy expert. These days he has done amazing prospective randomized studies of thousands of patients looking at various techniques, comparing different techniques for endoscopic removal, and the bottom line, based on his studies and other expert opinion, is that for these lesions, M. R is the standard of care. It's proven to be safe, effective and cost effective compared to SD e s d. On the other hand, really is the treatment of choice for patients who have a superficial cancer like a t one, a cancer where you want to get an on block or section. So sometimes biopsy comes into that sometimes it depends on local expertise. I don't know if the keels on, I'd be curious to hear what his approach would be. Looking at this if he would go straight to SD or if he would just do a standard m r, I would do a standard EMR um you know, one of the things that I think was really important that Steph highlighted was, um, you know, when we see these larger lesions, we kind of in our head are going through all of these checklists of things. So what's the pit pattern? What's the Paris classification is a granular is non granular because we're looking to differentiate higher risk features. Um, that would pretend more of a diagnosis malignancy, which would change our approach. But, um, Chris is exactly right with the majority of these lesions. Um, if there's no superficial cancer, you can respect them quicker and safer. Um, and with equal effectiveness with EMR compared to the S d. The only real benefit to SD, um, is when you get into that superficial cancer and you need to ensure that you have negative lateral and vertical margins to ensure that you've been able to, uh, completely achieving our zero reception. So, um, you know the other. The other thing. When we do these cases, you don't have to get super aggressive with a big scenario. You can do it piecemeal. And, um and, uh, you know, just make sure that you're able to completely take down the polyp sort of piece by piece. It doesn't have to be in 11 big piece. And so there's often times it will do repeat injections to get some coastal lifts. Um uh, during during these larger receptions, they have newer, commercially available inject states that we have in our Endo unit for these types of lesions where you can have a sustained lift because that's really our safety margin to really get a good semi coastal cushion. So we reduce the risk of things like perforation. And that's why we asked our referring us to not extensively biopsy into not tattoo under the lesion because those will make our reception a lot more harder and to the point I was making earlier about taking the time. So yesterday you Kira scoped with me and we had on our schedule a patient for follow up follow up colonoscopy after we had removed 2.5 centimeters sequel Polyp about a year ago. His follow up got delayed because of Covid, and his prep at the initial time was not great. When we went in yesterday, the sequel site looked pristine. We saw a nice car, but on the way out we found not one but two laterally spreading to us. One was three centimeters in size one was 3.5 centimeters in size, and it completely delayed our entire day because we hadn't had it booked. We hadn't planned on doing any more big Myanmar's Shout Out to You, Kira for a fantastic job of removing the 3.5 centimeter lesion. But, you know, again, it was it was It's just part and parcel with what we do. And I think you know, hopefully we say that guy right Hemi collected me so um great. Awesome case. Thank you very much. Great discussion. Uh, I'll turn it over to Stephanie. Privilege. This is my zoom debut, but can you see my screen? Yeah. Good. Okay, perfect. So my case is a Oh, yeah, perfect. So I'm going to present today a case that we came across on service. It was a few months back with Maya Cal, and it was the case of an 85 year old lady with a pretty significant past cardiovascular history. She sort of had the whole shebang Prayer stroke, C a d with a prayer, my DVT on Coumadin, chronic kidney disease, which was pretty advanced hypertension and gout. So she presented to the E. D. With this diffused, sharp, non specific abdominal pain with no alleviating or exacerbating factors. She's been having loose blackish stools for the past week and then, on the day of presentation, develops nausea nemesis, which is what prompted her to come to the emergency department. She never had an e g or colonoscopy, because in her own words, she was too scared. Which sort of reminds me of the other Stephanie's patient, who thought that they were too invasive, and I just think it's it's it's sad and sort of I know something Our institution is working on a lot, but she's a very elderly black woman who has never been screened for colon cancer, and she has reached the age of 85. And it sort of just It just reminds me of patients misconceptions about what the colonoscopy involves. Um, I guess in her case, well, I'll tell the story first. She had labs that were notable for elected of 5.5 on arrival, which improved the twos. Her hemoglobin, I think, was concentrated on arrival because it was 4.2, but then went down to 10 after some I V fluids. Her white count was impressive at 20 then 25.6 with 8% bands and a left shift. She had an iron ore of 2.4, therapeutic for her use of warfarin. So I examined her in the e. D. I actually remember it vividly because of her rectal exam, so her she wouldn't really allow me palpate her abdomen because she was very tender. She didn't have rebound or guarding, but was just extremely tender throughout. And then this is what I put in my note prior to the scope, but she had this bright red blood with Puss, and it almost looked like current jelly. I've never seen anything like it. And it was just losing out onto the bed and the e d. So that is sort of them imprinted in my mind now, forever. But we saw her and we decided to go to Flex Sig. We didn't want to do a cat scan because of her renal function, but we were unsure what was going on. And this was what sort of a scary sight that greeted us as we sort of came up to the rector sigmoid. So you can see in sort of the six o'clock to eight o'clock range on your screen that there is gray mucosa that looks Nigel her with a almost a pure violent exit eight over it. And then the mucosa in the remainder of the screen is erythematosus granular, and it looks hemorrhagic. And to me, it seems like the mucosa in the gray segment was looked like dead mucosa. To me, it looked like it was it was pretty horrifying. It looked like it was no longer living we didn't know what this was. I think we called to teach into the room, uh, as as typical as to find one of the advanced endoscopy attendees and ask them what they think. And we wondered what that like, the single stripe sign from ischemic colliders. And then we decided at that point to get her a CAT scan because we've been holding off giving her creating. But at this point, we were concerned about her mucosa. And here's just some stills. So you see this Horrible? Yeah. Disgusting looking mucosa. Um, up here and then these are just our biopsy sites for the mucosa and normalizes as you come out of the sigmoid and up to the descending colon up to the Spanish lecture. So we were very worried about ischemia, and so we decided to go ahead and get a cat scan same day and Joe diffuse Kalanick wall thickening. So you see here the contrast is in the Lumen and that's only a little little segment of gloom. And the rest of it is very thick wall here in the rectum, the same and then another segment over here. So the read, however, from radiology, was that this was to the market, def. Useful thickening and throughout the colon argued against ischemic etiology, which was interesting because we didn't go all the way to the second, but the because I looked like it normalized beyond the sigmoid. And so the pathology came back, showing mildly active colitis and marked acute inflammation in the colon and the rectum. And they also felt that infection could not be ruled out, which was unexpected. We when we got this back, we spoke to the team and they checked C D F and G I. P. C or both were negative, and at that point she was having no diarrhea, um, to give you follow up. She's actually done very well through Covid and is now she's at home having no G I symptoms and being seen by the visiting doctors every few months. And she's actually she has done fine. She's never come back to GI Clinic or had a repeat colonoscopy. But I think she's made a full recovery, so I don't I actually would argue that I don't think she needs a repeat col colonoscopy. Um, just a quick overview of I'm gonna consider continue to present on the scheme of colliders, even though we were told that it was. And I do think that given how tacky Carter chemo concentrated, she was coming in with current red jelly black appearance. I I still believe it was a scheme of colitis, even if the pathology and radiology don't exactly bit and the etiology is decreased perfusion to the colon and the there can be two types. One isn't just mucosal injury. The other is full thickness and process with gangrene, which is a much worse outcome. The incident is 4 to 5400 person years, and patients can present with the self limited, vague abdominal symptoms, which was definitely her very non specific. The black stool, the nausea, the pain. But the risk factors are aged over 65 we believe female gender, constipation, systemic arterial disease. So she had three of those and in most cases are transient and resolved with conservative management. And there are There's a real spectrum where patients who just have a little bit of bleeding after they didn't feel well for a day or two and who do fine. And I think the voluntary faculty have told us about those patients that they see in the office who who recover after one day. And I think we see the other end of the spectrum in the hospital as fellows. These are the areas where that are most commonly involved there, the watershed areas where at the anastomosis of these branches, and they're highlighted here with the then director sigmoid enough Hispanics lecture so they're the most likely to be affected, and ischemic colitis is most of the time is a low flow state, so it's not that they've thrown off Trump. It's it's bad you're not your overall, not perf using well enough. And the distal parts of those arteries are not getting enough blood flow. And the question that I have, because it it comes up all the time and we hear different things depending on who were on service with. And I just think it's really interesting. Do we need to do a colonoscopy when when the story fits with the skin of colitis? So maybe in this lady's case, maybe we needed to, because it wasn't so clear and we couldn't get imaging. But currently the HCG does recommend that we do an early colonoscopy within 48 hours to confirm the diagnosis, and I've heard people argue either way the evidence out there a study by Dr Brandt is that colonoscopy helps you determine what part of the colon is involved by ischemia, which helps to predict your helps to risk stratify and prognosticate. We know that ischemic colitis on the isolated to the right side is worse than collided anywhere else. And so there's some of that. They are the reasons we do it. The other reason we do it, and the guidelines are based on this one trial out of Spain, where there were 364 patients were prospectively enrolled from this big hospital system that served 3.5 million people. There were patients with ischemic colitis who a GI doctor identified through looking at colonoscopies or the GI or surgical senses sentence from the day. It was a little bit of a self fulfilling prophecy in that some of the patients were found through their colonoscopy findings, which showed ischemic colitis, so the majority of them nearly all had a colonoscopy. 345. So they were looking at outcomes, and they showed abdominal pain without rectal bleeding predicts poor outcome. Nando diarrhea, peritoneal signs or isolated right colonic ischemia. And the 12.9% of patients had an unfavorable outcome either mortality, which was 7% or needing surgery. Their argument is that if we find isolated right colonic ischemia, that's much more likely to need surgery, so that someone that we would then be more concerned about you might be able to see that on imaging. But I think it less often. The other reason is that these are the findings that are that were found in that study, and erythema, oedema and viability as well as superficial ulceration has been the most common. And then there's this less common blue black modules with a dusty, a dark, dusky background, and that suggests gangrene, which does require surgery. And this is the image, um, included in the paper below. I don't I don't think our patients find a colonoscopy looked exactly like this one. Their rationale is that the sooner you do the colonoscopy, the more likely you are to find those hemorrhagic technologies, and you can see that the more days from Colorado Skippy the lower likelihood of finding this hallmark of gangrene, So I don't know. I'm still not convinced. I think that if the patient is elderly, peritoneal, science, rising lactate, I mean, then I think that that is an indication to go to surgery. And I think if we're worried about them, it's great to have surgery on board to monitor their exam and let us know what they think. But my feeling is that all the scheme of Kaluga should probably not be going for colonoscopy within 48 hours. Although they showed no adverse outcomes because they minimum are no increased adverse outcomes, they minimize the installation of air. I'm still not sure that it's that it's necessary, unless there's like many risk factors or something that's making you really concerned about a poor outcome or or full thickness necrosis suggestive of gangrene, then I don't think that we should be. But I would love to open up the floor to those who are more experienced and hear your opinions. So, uh, great presentation, A very interesting case. I am, uh, I'm in the camp that these patients don't need colonoscopy. I think in a lot of patients, this patient might have needed one because you've got the C t. You would have seen pan colitis, which, you know, it occurs about 5% of the time in ischemic colitis patients. So it's not classic, but we all know 5% is a real number. Just ask any ercp is to get the post ercp pancreatitis. Um and so, um, so 5% of ischemia patients have pan colitis. Okay, you're going to see that, and you're gonna see that more than once in your career. Um, so in this patient, I think they would have probably gotten to flex it at some point, if you see teach first and then flex it later because pan colitis didn't make a lot of sense. Um, but I'm generally in the camp that it's a fairly clinical diagnosis. Most of these patients have typical risk factors. Typical symptoms, and the scan will often show colitis in a consistent area. Um, the decision to go for surgery is not an endoscopic one. You can see mucosal, ischemia, even Nikko cell necrosis. But the reason to go to surgery is transmittable disease. Um, unless someone has a colonoscopy colonscopy finding that has a high predictive value for transmittal disease, I don't think there is a reason to be scoping all these patients. I'm going to throw a scenario out there. I think Dr Stein Hagen is on. So maybe he can comment. And certainly Stephanie, if your research and this has has come up with an answer. When I was a G I fellow, uh, not at Mount Sinai, we had a patient similar case, and the surgeons wanted were pretty animate that we do a flex sig and they were in the room and we did it. And they specifically wanted us to take a biopsy with the logic that if there was no bleeding on the biopsy, this patient had an a chronic bowel and needed emergency surgery. I don't know if Dr Stein Hagen can comment. Uh, I don't to be honest, you I've never heard that specifically. Obviously, we're actually more concerned about what's going on on the outside of the bell than what's on the inside on the outer wall, let's say than the inner wall. Um, there was a time Barry sake was doing laparoscopy in the EU to look at the cirrhosis to of these loops, about to try to determine if there was full thickness of ischemia. Um, and I think he was happy with it at the time. Uh uh. Bleeding on a biopsy. Quite honestly, I've never heard that as a criteria for determining anything. I think. More likely it's the clinical presentation. How much tenderness the patient is having a parent, Neil signs that are going to make me decide one way or the other. Yeah, I'd agree with that too. You know that We there's a lot of ischemic colitis where I see everybody getting lactaid. It's I'm institutions camp. Um, I don't think most of these people need colonoscopies. Um, but what I do see a lot which I would try to discourages this sort of use of, like, multiple LAC tapes over time. And once the person has a very high lactate, you know, they are probably developing the crisis in gangrene. But everybody else who's who's, you know, sort of mild doesn't need these serial lactate. So I think I certainly agree with that. I think lactate is a function of so many other things related to hydration status and liver function that it isn't really that it isn't specific enough to give you any real information. Uh huh. Great presentation stuff. Quick question. Um, how to what extent? This is city A really help with the diagnosis here. And oftentimes we might subsequently got a c t a. How does that help clarify what the theology is in a case like this? Yeah, I think I think it often does help when you have the right clinical setting. And all you just need to see is that watershed area described on the on the C t. And you sort of I think then you're done and the reason to do a ct eight my knowledge is looking for you're looking for news and therapists. Kenya. So you're looking for a tram bus and which is rarer but typically causes more right sided colitis. And that's something that at least my my practice has been that if we're maybe just checking the lactate just once a day, I promise elected is elevated, or the exam is concerning to get a c t a, um, to make sure that there is no like, there's no tramps that requires a tram back to me. And I always think it's nice because if you're like, I think this game of colitis. But if we're not going to scoop them, I'd love to information. But I'd love to hear what others are doing in the C. T is going to be normal and typical, um, scheme of colitis. The only time really to be doing that was when there's isolated right colonoscopy, mia, because then you're looking for a disease in the S m. A. Distribution. By the time you see the patient, in the vast majority of people with the scheme of colitis, their blood flows back to normal. The mucosal damage happened previously. It's going to get better. And all of the vascular studies would be normal. So I'd sort of discourage it. Unless there's right. And if you didn't have a colonoscopy, what would? So you didn't know that there was right Colin ischemia? Would there be anything that would push you to get a c t a. So remember the c t A. You know, you get an arterial phase contrast, which shows you if there is a conclusion within the vessel Now, most colonic ischemia, even right sided colonic ischemia is not vascular inclusion is all still low flow. Um, now what? A regular CT can tell you. And I'm curious to see what this lady C t is. You can actually look at the origin of the S M A off the aorta, and you can see if there's a lot of calcifications, and that will give you a clue to what degree of vascular disease you'll find. Most of these patients have calcifications at the take off their meds and Eric arteries, even an isolated right set of chronic ischemia. It's still usually low flow, but it's low flow at the distal S m A. And so it. What it does is it portends bad, sm a disease, which is a bad thing. But even still, when you have rights as iconic as the man still low flow, it's just low flow in a dangerous spot. Um, so the C T A. Generally is not necessary because that's only for vascular occlusion. So if you have small bowel disease, small bowel ischemia, then that's from dramas. And that's where the T to is really good. Yeah, just a couple of one point about that. Yeah, I had a patient who I was seeing in clinic who had actually admission since, like, 2000 and 17, mostly actually, just in the ER, where she'd come in with abdominal pain and then they would do a CT scan. They were thickening in the right side. You had a colonoscopy once or twice, which is consistent with the right side of the ischemia. But no one worked it up further. Um, and she was a clear vascular path, end stage, renal disease, the whole deal. Um, and we and she also had symptoms of chronic meds, interrogates ischemia like afraid of eating food, um, and pain after eating. And so we sent her for CTE, which showed pretty severe disease in the S m A and steal yak, and she ended up getting sent. And it hasn't had any recurrent emissions at this point, I think definitely to keep, like, not necessarily on the inpatient setting, but, um, for a long term management, people keep on having right side ischemia to think about that. Mhm. Yeah, what you're really saying is that interesting? I guess what you're what you're really saying is that the sea to is useful if you suspected thrombosis or an endless rather than just low flow. But in the absence of that I don't think the c t a. Is that useful? Exactly. Yeah, I guess. My question is, how do you like water? Is there? And does anyone have, like, is there a hallmark for more likely small bowel disease? I guess more melon, a pain lactate because sometimes it's hard to differentiate. And I'd like to avoid imaging if possible. Um, that's going to be your typical pain out of proportion and also patient at symbolic risk. So the eighth in patients, some of the young people in OCP, that kind of thing, um, they don't You don't typically have sort of diarrhea, Melina per se because it's so high up in the small bowel. Um, it's risk factors and that sort of typical story or exam, I think. Okay, Thank you from my perspective. When you see this woman elderly multiple risk factors coming in with acute onset pain followed by blood and a white count of 20 esky. Mia should be on the number one thing that you're thinking about for this patient maybe, I mean with the Lactaid exquisite, edited, cheap perf. So even with renal insufficiency, the first thing I would have done and I would have sent a C T scan on this patient as opposed to doing a flex sick. And the other comment is just because you saw that rectal involvement. That does not mean it's not a scheme that you can absolutely have rectal involvement when you have ischemic colitis and something that you're sort of taught in med school and residency. Always, it's usually involving these washers. No, no, it can involve any part of the call, including the rectum. So don't be fooled when you see that on the flex sick. Okay, but it often doesn't involve direct. Um, I mean, it's often an isolated area in the sigmoid explaining function. Yeah, I think rectal involvement is the exception rather than the rule. The blood supply is completely different. Yeah, it's enough small category of a few percent, just like it's there, but not your classic. For sure. This is a great case stuff, because it's got all these atypical features that allow us to discuss all this. So nice work. Mhm. Yeah, No. And great discussion, I think very, very useful discussion for sure Published December 4, 2020 Created by Featured Faculty Stephanie Gold, MD Internal Medicine Icahn School of Medicine at Mount Sinai Stephanie Rutledge GI Fellow, PGY5 Icahn School of Medicine at Mount Sinai
