Video Endoscopy Conference 10/9/20 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 10/9/20 Overview Two cases presented here: • 00:00 – Pancreatic Adenocarcinoma • 26:45 - Chronic Radiation Proctopathy So today I'm going to actually present, uh, an extra special case. We have a special guest, Dr Paulson, who's one of our intending pathologists here. And the case is called when you hear hoofbeats and let's get started. So first for the case presentation, Um, we have a 61 year old male history of chronic disease, such as opposed to multiple surgeries. That's probably not the standard not sign a way of describing various disease, but it's less relevant to this case. Um, he also has MPs. He had a stem cell transplant. He's coming in with painless jaundice on labs. CBC. Relatively unremarkable. Um, he has a little CKD on his BMP and his liver enzymes are elevated. S t. 1 54 l t to 98 Billy 12 out fast for 75. Uh, imaging shows markedly distended gallbladder common bile duct dilation to 1.5 centimeters with an abrupt termination of pancreatic head and in the pancreas, fullness in the head. No Frank Mass. No obvious PD dilation on this first imaging. So based on the jaundice and the imaging, he goes for endoscopic ultrasound and e r. C. P on the U s he has, as noted, Canada dilation to 13 millimeters. He the p. D is like borderline dilated. 3.5 millimeters in the head. And he has a mass seen in the pancreatic head. So it's about two by three centimeters. Undergoes fine needle biopsy on E R C p. He's noted, uh, you can see in the image to the left. He has a distal common bile duct stricture, and he has a metal stent placed. And now, Dr Paulson, if you want to flip on, we're kind of going to tag team this so that we can describe the pathology. Sounds good. So, Sherman screen Mhm. Perfect. Mm. Mhm. Mhm. Okay. Good morning. I'm John. So I'm glad to be here this morning to show some histology of this interesting case. So this is the first biopsy. This is the biopsy in its entirety. And when we take a look around the biopsy, um, in some areas just shows completely benign pancreatic acid. This is the nine pancreatic Aznar tissue with grape like arrangement of the assembly. And some fragments are completely obscured by this pink fibrosis. This piece of looks a little bit more busy and That's because the tissue is completely infiltrated by acute inflammation or neutrophils. And when we look higher power, we can see these neutrophils percolating throughout the tissue. And this fragment really has the key diagnostic feature for the histology. And that is a granule acidic epithelial lesion or gels, as we call them. And this is a histological feature that characterizes Type two autoimmune pancreatitis. So what is a gel gel? Really? Is just a complex of the pancreatic ducts with neutrophils, and they can have several appearances like here. Basically, the pancreatic ducts are packed full of neutrophils or intra Luminal micro absences, and occasionally the neutrophils creep into the duct. Epithelium disrupted and damage it. It's very reminiscent of what we see an I V D. When neutrophils in baby intestinal prints and in fact, type two autoimmune pancreatitis is associated with IBD, and our patient has IBD, so starting to look like this is type two autoimmune pancreatitis. But that sort of secondary my job when they see a mass, is to make sure that there's no malignancy in this biopsy material. These ducks are a little bit atypical, but they are being aggravated by neutral fields but we do stains for tumor suppressors, not four and p 53. And this was indicating these are benign ducks. And when talking about autoimmune, we also do I g four, which was negative. So just to get our bearings for arguing pancreatitis, there's two types like one is a type of really. The prototype. When we think about has the I. G four association has the store form fibrosis and lots of plasma cells, and type two is really different creature. It's what we're seeing here with the gels, the neutrophils in association with IBD. So signed up this case I described the histology and said suggestive autoimmune hepatitis type two in the appropriate clinical setting. I also have a little note down here, but I don't want to spoil anything. So I'm gonna leave that out for now before we go into the second privacy. So that's biopsy number one. Vicki John, That was perfect. I'm gonna steal the screen now. Yeah, alright. So based on that biopsy and the presumptive diagnosis of autoimmune pancreatitis, the patient was started on prednisone with the standard treatment for autoimmune pancreatitis. He stayed on that for four or five weeks. he had a repeat imaging. There was still some fullness in the pancreatic head, but maybe less conspicuous. The biliary tree was decompressed adequately by the stent and his labs and purposes. Billy came down. S clt alphas came down. Notably I G four was normal, although this is basically what you would expect in type two auto pancreatitis, which is what we suspected. Um, so he began tapering his prednisone and then he came back for repeat ercp for stent exchange or stent removal, Um, and another us to assess the pancreas mass that we saw last time. So in the U. S. Uh, actually, there's been some progression in some areas. The pancreatic duct was more dilated. Last time was 3.5. Now it's 4.3, Um, and it was 2.9 in the body, which is again a little bit above what we would expect in the body of the pancreas. And there's still a persistent mass. It's maybe a little hazier in this picture. Sometimes that's just imaging quality. Um, but it's definitely still present. Notable. I do not have Ercp pictures, but based on his improvement and the expected response to steroids that metal stent that we placed last time was actually removed. And now, John, you can go back for biopsy number two. All right, so biopsy number two. So this is the biopsy in its entirety. And when we take a look around, we see some similar findings that we saw before have some fibrosis. And then these, uh, neutrophils are acute inflammation infiltrating the benign pancreatic tissue. And in this fragment here, lots of fibrosis. Something we didn't have last time was fat necrosis. And we were talking in the department about this. Why would there be fat necrosis in this biopsy? Fat necrosis is not associated with type two or type one on pancreatitis. Um, so one of the things we thought about is this could be due perhaps to prior biopsy effect. It's a really non specific findings. We don't have any gels here, but some similar findings. And Dr Harper has actually signed up this case so acute and chronic pancreatitis with fat necrosis and this fat necrosis could be contributed to private types and the correct clinical setting. This could be associated with type two autoimmune pancreatitis. It's really non specific, but importantly, no malignancy in this biopsy material. All right? Now, back to the case. So, based on the fact that he stole the presence of the mass, he still had biopsy evidence of autoimmune pancreatitis. He was restarted back on prednisone. 40. So the Taper was brought back up to the standard dozing to see if we could get this better. Um, And then after only two weeks, this time, he had repeat labs, and he just had everything that had gotten worse. Unfortunately, got more jaundice as Billy was up to 9.6 out, fastest over 1000. Everything was worse than than it ever was. So he came back for her again. Repeat the R C P U S on us. He has really a more distinct head of pancreas mass. At this point, you can see this hyperbolic OIC mass here. And he had another fine needle biopsy E R C p. Again, a very, very tight structure in the distal common bile duct. He's standing. He actually had a little bus in there as well. So, John, you can take us through the final path. All right, so this is the third biopsy in its entirety. And when we take a look around we see here some very atypical cells, very a regular nest. And this trauma is Desmond. Plastic has this hazy blue look to it, and the cells are very typical looking high power. We see the atypical nature of the nuclei, hyper chromatic and squished. And the cytoplasm is also a typical very phony. And there's some single atypical cells as well. In, you know, stains were smacked, forced the loss of tumor suppressor snack ford and over expression of P 53. This is very clear cut pancreatic adenocarcinoma. So it's, uh, invasive. Moderately differently. Differentiated adenocarcinoma and increased massive biopsy. It's also a bio duck. Scripture biopsy showed exactly the same morphology. Cancer in the Bible. Scripture as well. Um, you want me to go into this study, actually explain that, Uh, so this is a reference actually cited in the first biopsy report. Um, and, uh, it's a study that's done at Cleveland Clinic and University of Chicago. And it explains, basically, they had, uh, pancreatic ductal added. Of course, no one can have autoimmune like histological features associated with it with around it in the midst, the tumor. So it was a study of 105 reception specimens for pancreatic ductal cancer. 65 of them showed chronic pancreatitis in 10 of them had autoimmune features, and the conclusion of the paper basically was caution is necessary when making a diagnosis of autoimmune pancreatitis by needle biopsy of a mass lesion and in patients with the tentative diagnosis should be closely followed up clinically, which the clinical team did wonderfully. And here is the table to from that paper showing the different AI p features that you can see and pancreatic ductal adenocarcinoma around it in both within the tumor. Um, most of these cases had extensive pancreatitis, and half of them actually have gels like we have. So the jealous can. Actually, when we get the reception, specimen will probably see gels involving benign epithelium and the cancer. So will be interesting to take a look at that, um, so back to buy up someone. So because Dr DeMeo and Nick saw a mass just sort of cover bases or cover tail, we mentioned that 10% of pancreatic cancer can be associated with these ai features. So this is just yesterday from the gross room, the gross respect in specimen. From this patient, we can see that there is white firmness within the pancreas. So down here is the bleak A circularity to duodenum. And this is the pancreas. This yellow ink is the common bile duct. So we have this firm lesion here, pancreatic cancer. That's involving the common bile duct. And here in the background, you can see the lobular of a nine pancreas more yellow in color, so the slides aren't out yet, But we'll probably see perhaps some remnants of the Ottoman pancreatitis, but definitely cancer. All right, fresh off the presses. Thank you for that update. We will await the final resection specimen. I have just a couple of extra learning points to go through, so I'll share my screen again. So I think the big overall teaching point and take away from this point this, uh, presentation. And the reason I called it when you hear hoofbeats is that this patient presented with painless jaundice and a mass in the pancreatic, So you always have to think there's pregnancy. Your suspicion from pregnancy should be very high. And despite a couple red herrings, you know, the IBD, the unusual biopsy. Um he didn't respond to steroids. And, uh, persistence eventually proved that he did have cancer. And so I'll just share a couple. We went through the pathology, Um, that can help differentiate autoimmune pancreatitis or sometimes be a little confusing. And and cancer versus autoimmune pancreatitis. I'll present a couple clinical elements that can help differentiate autoimmune pancreatitis from pancreatic adenocarcinoma. So here's a few like a table that sort of breaks them up by different criteria. Um, first of all, imaging, which will look at a picture but in autumn in pancreatitis, can often look like diffuse enlargement of the pancreas. With the capsule like Rin and the features of pancreatic adenocarcinoma, you might expect our mass, although that can be seen in either one of the key differences with cancer. Are you going to see duct dilation or duct cut off and upstream atrophy? And so one of the red flags in this case was that he had progressive duct dilation on us, and that's a little more suggestive of malignancy rather than autoimmune, where you might expect a normal doctor, um, on serology. If it's type one, you might have an I G four. Although we suspected tattoo, so that didn't necessarily help us in this case. And similarly, with pancreatic cancer, you might see an elevated C in 99 although that can be elevated in many forms of sort of pancreatic biliary disease, especially with biliary obstruction, is in this case, so that wouldn't have necessarily guided us, either. Here's just an example of that. Those imaging characteristics I was talking about so on, uh, the upper image? A. You can see this just diffuse the enlarged pancreas, and that hypoxic OIC capsule and Slide B is a more subtle form, with just focal and large pancreatic tissue, but no duct dilation or a trophy and and see you can see you can't really see the mass, but you can see this mass in the body. Here. I'll point it out this hyper dense mass. And then this is the dilated duct, and there's just a trophy of the pancreatic tissue upstream, so that's more suggestive of malignancy. Other clinical features are in autoimmune pancreatitis. They may have involvement of other organs, especially in type one, so they can have diffused IgG four related disease, including biliary strictures, Reno involvement, retro peritoneal fibrosis or product or lack formal grand enlargement. Type two Autoimmune, uh, is often associated with IBD. As we know. Unfortunately again, in this case, that was another red herring and patient did have IBD, but he didn't have auto. So, um, pancreatic adenocarcinoma, obviously you would look for Metz. You're never going to see mets in autoimmune pancreatitis. And lastly, and I think the most important in this case is response to steroid treatment. So auto mean pancreatitis tends to respond very well. The pancreas to steroid treatment, especially type two and pancreatic adenoma is not going to respond. So that was really the clincher in this case, and that's it. Thank you. Does anyone have any comments or questions for me? That was, uh, first of all, thank you for a great presentation. And, John, thank you for the, um, excellent, um, path size that you showed. Um, for me, the second e u s, um, whether after the patient had been on steroids, that was really a big red flag, that you still had a mass there. There's really no response to the steroids. You still had the, you know, even worsening pancreatic ductal dilation that this is not just a pipe, and our awareness has to be heightened. Um, for for pancreatic adenocarcinoma. Um, any other comments? Questions, Um, for this case is a great case, so I just I just chat. I'm sorry. Go ahead. Sorry. The reason for putting in a metal sent Maybe I have the wrong impression. My head. But I would have thought it might have been a plastic stent because we thought it was going to be a temporary thing until he got better on steroids. Or can you guys help me understand that? Yeah. I think either would be appropriate in this case. Chris may be able to comment more, but it was all know what it was I didn't mention it was a covered metal stent, So, um, it was not a permanent step. So we did actually remove it after a few weeks. Um, and Chris, I don't know if you have more comments about that specific choice. Yeah, and I'll echo the sentiments. Uh, thank you both for phenomenal presentation. Uh, so when I first when I first saw this patient, when I did the first endoscopy, I came out and told the patient and his wife that I think he has cancer. Um, and our suspicion was so high up front during the initial us that we put in a fully covered removable metal stent. The thinking being that, uh, if he was going to get some type of chemotherapy, he wouldn't need to come back for a stent change before surgery. Um, so that was the thinking there. But you're absolutely right. Plastics. That would have been just as reasonable. Um, and then, as has been pointed out, the two red flags for me or that his after the steroids, his labs never really got normal and the mass or fullness and went away. And that's not typical for autoimmune pancreatitis. Usually these patients have a rapid response to steroids. So much so that if the suspicion is high upfront, we often won't even put a stenton. You'll give the biliary obstruction will go away. And that was really the tip off to all this. On the third round of endoscopy, we took the stent out and endoscopy number two And then, like 10 days later, he was jaundice. I put him right back on steroids and he did not get better. He just sort of progressed right ruit, and it was pretty evident on the third endoscopy that he, uh, that there was something other than autumn pancreatitis going on. And the other point I'll make real quick. Is that with with the two different types of autoimmune pancreatitis, as as keeps getting mentioned? Type two is the one associated with IBD. But it's been pretty well published, and it's been our experience that type to boot present with effective John does it typically presents more as a recurrent or smoldering pancreatitis, meaning patients present with acute pancreatitis. They never really get better, and it just sort of lingers for weeks and months. This wasn't the case, so it would have been a very atypical presentation of Type two Auto Citizen again, in our experience with the type to DVD, it's usually younger people in their teens say forties is the more classic population. So, you know, I think Nick said it best when you hear hoofs think horses and not zebras. Because 99% of the time somebody comes in with Hank Mass and jump on this, it's going to be cancer. Pancreatitis is just relatively rare. Mikhail can assess them, Um, so yeah, Nick and John. Great. This great presentation. That's an amazing case. Um, Chris and I share a young patient with type two autoimmune pancreatitis and distal colitis, Actually, and it's been really dangerous. Locked him because it has all the features that Chris just said is pancreatitis sort of smolders along at times. Um, but I think the key to this whole thing was the non responsiveness to steroids. And good for you guys for being persistent, you know, and keeping after this and ultimately getting to the diagnosis. What did you what happened to the patient? Like there's a whole roller coaster for him, right? Um, Chris, you told him? Probably had cancer. Then he sort of didn't have cancer. Like, how did he take all this? So, you know, normally. So initially, you know. So I think you have cancer. The biopsies came back. We were all very happy. And after the first round of after the I really think Dr Paulson for putting that note in the original biopsy results because I told the patient and his family After the biopsies came back, I said, it looks like autoimmune pancreatitis. We need to keep like a 5% suspicion that there's something else going on. So that was really key for me. I think I've heard this maybe like a case report from Japan about this phenomenon of a I. P type changes in pan cancer. So I planted to see the the patient, and then I just sort of kept them at bay the whole time that I don't think we're completely out of the woods. This is Peter Rubens patient. I don't know if he's on the line, but you know, he appropriately he's been around a lot longer than all of us. He he appropriately said, Are you sure we're not missing cancer? You sure we're not missing cancer? And again I said, You know, we're keeping it in Look back of our mind. All of the evidence we have is that there is, but it has been pointed out. The labs never really got better. The mass, the fullness never really got better, and that's really a typical for autoimmune. So this is a collaborative effort in this case, and I think the pathology team really helped keep us on alert that we have to. We can't rest on our laurels and just say, Well, why aren't steroids working? Well, um and I think And you know, John, maybe you can You can comment, You know, there's this other phenomenon is autoimmune. Pancreatitis started to become more recognize that that the tumor itself can just cause inflammatory changes. Auto immune or not. And sometimes you give steroids and those Perry to moral inflammation. Nation goes down and it actually makes the mask. And it's more evident on imaging or us. And I suspect that may have been the case here, but I don't know if you have any comments on that. Yes, absolutely. Sometimes even in in biopsies of, uh, uh, pancreatic cancer, we can see an acute pancreatitis associated with it. And they, due to the damage, is causing to the ducks. Absolutely. And I can imagine after giving steroids, I don't know what we'll see in the reception is best known for. The reception will be very interesting to see what we see if we do see residual autoimmune like features or after the steroids on the second specimen. Um, there was a comment about fat necrosis. Can you can you talk a little bit more about that? Sure. Fat necrosis is not something that we see his logically associated with. Autoimmune pancreatitis, usually more with alcoholic pancreatitis. Um, so that really You know, it made us question whether or not the patient had autoimmune pancreatitis, but because the patient was biopsied. It could definitely be due to biopsy trauma. We occasionally do. See. And I talked with doctors who used to be a pancreatic pathologist here, and he says, sometimes in biopsies, uh, where the patient's been biopsied a couple months before You can see fat necrosis due to biopsy passes. That's very unusual in our view. Next answer this great learning case. Um, I just have a question. What do you think? Different. And the diagnostic you can this time around. Was there anything different that you guys did? Like Hillary biopsies, as opposed to just mass core biopsies was addressed. It was all the same. It was just repeated efforts, I think, um, and getting enough tissue. And then perhaps as we were talking about as the inflammatory aspect of it went away with steroids, maybe that helped make it more clear. I don't know, Chris. How many other thoughts? Yeah, I don't I don't have a great answer because we biopsied. We took core biopsies all three times of the same exact area, so I don't have a great answer. We did on the third round. Take bile, duct biopsy. Is it the RCP which confirmed the just but the core biopsies made the diagnosis on the 3rd 2nd biopsy came back. You know, I spoke with with John and Gnome, and I said, You know, what is this? Is this consistent with tree? Yeah. The autoimmune pancreatitis is this, you know, And because there weren't g d l do at that point. So it seems like the auto mean features were going away are improving. Um, and I don't know, I I don't have a great answer. It this case scared me. We see obviously a lot of both diseases here, and this is the first time I've ever seen this presentation of of this or combination. Very scary. Really interesting case. Yeah, I I had actually gotten a call about this patient after they got their repeats C t scan, um, and was and they had recurrent jaundice. And that's and I looked through the case. And so it's really interesting to see the follow up And what? The results. Um, I used to do pancreatic cancer research at one point. And one thing that we were always looking at is how a lot of the tumor actually. Is this infiltrated? Immune? Infiltrating how that might drive the pathogenesis. I've never seen this clinically, so it's really, really interesting case and good learning point to keep our eyes open if we see this again. Great. Um, thank you both for that. Um, really great case. And great teaching and learning points, uh, two things before we switch over to our next presenter. Um, we're gonna do a hard stop at 7. 55. and I just put a link to our grand rounds in the zoom chat. It's going to migrate over to UC Health. Zoom for our grandson, Speaker Dr Samir Gupta. Um, and then secondly, welcome to Jerry, who has joined his own conference and the longest running industry conference, uh, in the country. So let's, um Let's switch over to our second speaker this morning. It would be Dr Christine away. Uh, Dr Christina Wang. Um and, uh, you can share your screen. All right, one. Hi, Jerry. We miss you. all right. Can you see my screen? We can okay, everyone in one of the second year, fellows. Um, the case I'm going to present today is a 74 year old male with a history of hypertension, prostate cancer on Lupron and Cadaques previously received radiation back in January 2019 as non ischemic cardiomyopathy. Coronary artery disease TV. Tianna picks the band who was initially admitted for management of the Compensated heart failure with his hospital course, complicated by three episodes of bright red blood. Correct, um, for which he I was consulted. UN assessment. He denies pain associated with passage of blood, diarrhea, abdominal pain, nausea, vomiting. He's never had rectal bleeding in the past. His vitals are stable, but his labs are notable for hemoglobin dropped from 11.6 to 10.4 around the bleeding. His I N. R. Is 1.8, and a rectal exam did not real any hemorrhoids. What was notable for red tinged stool? We then performed a colonoscopy and the rectum Coastal was notable for this pale, friable endemic disappearance, as well as the distinct telling jacked Asia's, which can be multiple, large, indigenous, consistent with new coastal features induced by radiation injury. In certain cases, strictures, alterations, fistulas and areas of the cultural hemorrhage can also develop in the rectum. Mhm based off of these findings, um, and the lack of alternative causes to explain his dramatic easy on completion of the full colonoscopy. His rectal bleeding was felt to be secondary to radiation product apathy, which we subsequently treated with the application of argon plasma coagulation. Yes, speed things along the interest of time. Um, so today I'm going to speak a little bit about chronic radiation prop topsy, which is simply defined as epithelial damage to the rectum from radiation that is associated with minimal or no inflammation. Oftentimes, you'll hear people refer to this entity as radiation prostatitis, which is in fact misleading since it inaccurately implies a chronic inflammatory condition of the rectum. Okay, chronic radiation Prak toppy occurs in up to 20% of patients who receive pelvic radiation. It's characterized by this obliterated or ischemic and arthritis of the sub mucosal arterials, sub mucosal fibrosis and neo vascular realization. It usually manifests as rectal bleeding about 8 to 12 months following radiation treatments, but symptoms can occur at any time up to 30 years after exposure. Other symptoms include obstructive defecation due to structures leading to constipation, rectal pain and urgency. The likelihood of development of radiation product, aka fee, is associated with both radiation specific factors related to the dose, area of exposure and method of delivery, as well as patient specific factors. The management of radiation product apathy can really be bucket ID into three broad categories. Endoscopic interventions, which we'll talk a little bit about today. Medical therapies, which includes super fit enemas, short chain fatty acids, enemas, Metro night is all sofas, housing, hyperbaric oxygen and finally, surgery when endoscopic and medical treatments have failed. Unfortunately, there have been no large controlled trials evaluating the treatment of radiation product apathy. And as such experiences derived mostly from case reports and small clinical trials. In 2019, S G E actually published a guideline that focused specifically on the available and this Coptic interventions that can be utilized in the treatment of radiation product apathy. And as such, I thought it would be useful to read this today, starting with a PC, which is the most widely available and one of the most popular interventions for radiation product apathy. It involves short non contact applications for 1 to 2 seconds of ionized argon gas, which is applied to the target tissue through the tip of the probe. When treating these lesions, you should focus on a targeted approach and try to avoid painting the surface, which will create more extensive ulceration and increase patient discomfort. Caution should be taken especially with anti coagulated patients, as subsequent inspiration can lead to significant bleeding. The most common A PC related adverse events. Pain, which can be related to either alterations caused by the treatment or excessive valve distention from the installation of argon gas. Other advanced adverse events include strictures, fistulas and perforation. Chronic explosions have been reported in two poorly prepped patients who had only received an enema prep before a PC and as such, the adequate bowel preparation is needed before initiating treatment. In this guideline, a systematic review was performed on 33 studies that reported the efficacy of a PC for rectal bleeding on a total of 950 patients with chronic radiation product apathy. A pooled analysis of these studies found an overall clinical success rate of 87% utilizing a PC The average number of treatment sessions for a PC to achieve bleeding control range from 1 to 3.7, with the time interval between treatment sessions ranging from 2 to 8 weeks. But most studies reported a 3 to 4 week interval to allow enough time for the injured mucosa to heal. One study directly compared a PC to buy cap for the treatment of radiation product top of the and found it to be equally effective. The randomized study involved 30 patients with recurrent rectal bleeding and found no significant differences in clinical success, which they defined as the eradication of all to inject Asia's no significant difference in mean number of sessions needed for eradication and no significant difference in relapse rate of rectal bleeding during an average follow up period of 12 months. However, a higher rate of bleeding from ulcers was noted with by cap as compared with a PC. For Merlin is another intervention in the treatment of radiation product apathy and it can be applied and microscopically or instilled by our surgical colleagues. It acts only on the superficial mucosa, resulting in rapid deterioration of mucosal blood flow and coagulation necrosis. Several small studies have demonstrated an improvement in bleeding with formal and application. However, there are only two studies that directly compare the effectiveness of a PC with topical formula. The first was a cohort of 25 patients with rectal bleeding with clinical success defined as an improvement of hemoglobin by 10% or normalization of hemoglobin. 79% of patients had clinical success with a PC, compared with 27% treated with formalin. The average number of treatment sessions was similar between both a PC and formal in. However, the A P C group had fewer adverse events to find this nausea, vomiting, rectal pain and fever compared with the formal in group. The second study involved 30 patients with intractable rectal bleeding, meaning they had at least one episode per week or required blood transfusions or both. Leading cessation was seen in 94% of patients treated with a PC, versus 100% of patients treated with topical formula. There were no significant differences in the efficacy and durability of bleeding sensation between the two groups, and both treatments were well tolerated without any adverse events based off of these limited comparative studies, HSG currently recommends against the use of formula and compared with a PC because of higher adverse event rates with formula. However, the recommendation is conditional with the quality of evidence being low. Finally, radio frequency ablation, which is well described for the treatment of Barrett's, has also been employed in radiation product apathy. The depth of penetration Oblates the epithelium in the muscularity mucosa without injuring the sub mucosa, thereby restricting treatment to the superficial service and avoiding deep tissue injury as opposed to a PC where multiple applications can lead to deeper levels of injury Resulting in ulceration within the systematic review were three key series involving a total of 66 patients that examined the effectiveness of our survey and radiation product apathy. The largest study consisted of 39 patients with rectal bleeding who had failed prior medical therapy. Rectal bleeding improved in all 39 patients with pre RFP hemoglobin level of 11.5 11.8 post RFP hemoglobin level 13.5 after an average of 1.5 sessions and a 12 to 16 weeks time interval between treatment sessions. There were no reported serious adverse events in this series. Unfortunately at this time, there are no comparative studies or randomized trials to evaluate the effectiveness of our F A for radiation product apathy to summarize a PC by Cap Heater probe and are they are suitable options and the treatment of bleeding from radiation prak topics. However, there is currently insufficient evidence to recommend one intervention over the other. I'd like to now open up the discussion to the group to see what others have utilized in the treatment of radiation product apathy, especially in cases of recurrent bleeding in patients who have undergone prior applications of a PC. Thanks, Christina, for that presentation, Um, anyone have any comments? Questions on therapies for radiation? Proctor apathy? I could share a case. We had a case of refractory a PC that we did our FAA on, and it worked great. Um, patient tolerated it well, and I think we only had to do to treatments, and it kept him out of the window unit. His hemoglobin went up, uh, same thing similar as what you reported. I think we've also all used a r f a forgave for bleeding gave, and that's also been refractory to, um, a PC or other therapies so it's safe. It's pretty easy to use. Work seems to work well. Any kill, it's, um it's Dave. Christina. Thanks for clarifying product apathy versus prostatitis. But the most important thing here is Jerry's waving us. And so call on Jerry, please. Hi, Jerry. At the beginning, I was the only one who had an A P C in the tri state area. And there were a lot of patients having bleeding from radiation cocked apathy, and I was able to treat a lot of patients. So I had a tremendous experience with using a PC. Um, I cautioned one thing, though, Um, one day, um, patient was transferred to my office from Brooklyn Uh, with, uh, severe bleeding from, uh, well, it was thought to the radiation parked opposite six guys brought him into my office, and he was uptight, undid. I put the scope in and saw. All I saw was stool, so I asked the guys who came with him what kind of preppy had So they said, uh, he was so out of it that, uh, he couldn't drink any of it. So I screwed around with my scope and saw underneath all that stool was a lot of bleeding. And, um, it was obvious from radiation, So I thought, Well, what the hell he's here and I'll give it a trial. Maybe I can do something. So I washed a little bit of stool off and the first application of a PC, I heard an explosion. Um, instead of being in the rectal mucosa, I was looking at the floor with the scope and, uh, I was sure that I had exploded this guy. So one thing that you have to keep in mind is, even though you're just going to treat the rectum, you have to clean the whole patient because there was a lot of, uh, obvious explosive gases inside that I hadn't done anything with. This was long before we used c 02 so I cautiously looked inside, and, uh, actually, there was nothing. There was no damage inside fortune. It was only in an inch or two, and the explosion caused the scope to be blown out of the rectum instead of blowing up the rectum itself. So, um, I was really invited over to Cornell University to Cornell Hospital, uh, to speak before the radiation oncologists because, uh, they wanted to see. But this new therapy was, and actually we did very well and put the treatment of a PC on the map. I caution one thing. You don't just put formal in the rectum because there was some some patients that had that and reports long ago that you can shrivel up the rectum by putting formula in what the surgeons do. They put 10% or even 1% formula on guard strips and through a prop to scope. Lay the gauze strips on the mucosa and leave it there for 10 minutes. So you don't just put formula in the rectum and expect it to work. That's enough. Yeah, that was awesome. Thank you, doctor. Way as always. Um Published December 4, 2020 Created by Featured Faculty Nicholas Hoerter, MD Advanced Endoscopy Fellow Icahn School of Medicine at Mount Sinai John Paulsen, MD Attending PathologistIcahn School of Medicine at Mount Sinai Christina Wang, MD Icahn School of Medicine at Mount Sinai
