목차 · 2016. 1. 26. · 30 2016 gastroenterology Winter School. Take-Home Message Looking on the proximal sides of folds Adequate of cleaning Adequate of distention : air , position

목차

빈틈없고 안아프게 대장내시경 하기 ………………………………… 7

대장 염증성 병변의 진단 …………………………………………… 35

대장 종양성 병변의 진단과 치료 ………………………………… 73

2016 gastroenterology Winter School

Session 3. 대장

빈틈없고 안아프게

대장내시경 하기

김 은 란


통증을 유발하는 원인

과신전에 의한 내장통

- 삽입된 내시경이 대장을 밀어 붙이는 기계적인 힘

- 과다한 공기의 주입

환자 스스로 느끼는 지각과민

대장의 해부학

고정되는 부위 : 직장의 복막 반 이하, 하행결장, 상행결장

고정되지 않는 부위 : 직장 상부, S 자 결장, 횡행결장

고정점 : 하부직장, S자-하행결장 접합부, 비만곡부, 간만곡부, 맹장

대장내시경 검사를 시작하기에 앞서..

빈틈없이 안 아프게 하는 대장내시경

Eun Ran Kim, M.D. Division of Gastroenterology, Department of Medicine Samsung Medical Center

2016 gastroenterology Winter School 7

Ideal Distance

Cotton PB et al. Practical gastrointestinal endoscopy: the fundamentals. 6th ed. UK. Blackwell Publishing, 2008

대장의 해부학적 구조

8 2016 gastroenterology Winter School

대장이 과도하게 긴 경우

- 여성 > 남성, 고령환자, 만성변비환자

유동성이 심한 경우

- 성인의 약 15% : 태아발생과정에서 하행결장의 장간막 고정변이

- 횡경막결장인대의 유동성이 심한 경우

장 유착이 있는 경우

- 자궁 적출술과 같은 부인과 수술, 복막염 동반한 복부수술

게실질환이 있는 경우

장의 팽창에 대해 민감성이 높은 경우 (e.g. 과민성 장 증후군..)

대장 정결이 제대로 안 되었거나 적절한 전처치 약물의 투여가 안된 경우

★ 자신의 실력과 포기할 timing을 잘 알아야 한다!!!

이런 환자는 내시경이 어렵다!!!

안 아프게 하는 대장내시경



Neutral or straight (중립)

대장내시경 삽입의 기본 수기

선단부 굴절 (Tip deflexion)

밀어넣기와 뒤로 빼기 (Push-in and pull-back)

축 비틀기 (Torque)

송기와 흡인 (Suction air frequently, less air)

가볍게 흔들기 (Jiggling)

주름걸어 당기기 (Hooking the fold)

시계방향으로 축 회전 (Right turn shortening)

미끄러져 들어가기 (Push-through and sliding)

복부압박 (External compression)

체위변화 (Position change)

Always neutral or straight


Air suction (공기 흡인)

굴곡이 있는 부위의 앞쪽에서는 흡인 조작을 충분히

해서 굴곡을 최소한으로

상행결장 삽입시 유용: 공기 흡인 만으로 내강이 끌어

당겨 지면서 밀어 넣는 효과

Torque (축 비틀기)

한쪽으로 비틀어 통과한 후에는 반드시 반대쪽으로 비틀어 중립상태로


Pull-back in transverse colon

Push-in and pull-back (밀어 넣기와 뒤로 빼기)

내시경을 빼는 목적

- 충분한 시야확보

(무리한 전진은 합병증으로 연결된다.)

- loop를 풀기 위해

내시경을 밀기만 하면 다양한 형태의 loop가 만들어 질 수 있다.


Hooking the fold (주름걸어 당기기)

Jiggling (rapid to and fro motion, 가볍게 흔들기)

장을 단축하거나 직선화시키고 싶은 경우 언제나


Right turn shortening (시계방향 축 회전)

내시경의 축을 시계방향으로 비틀면서 뒤로 빼는 동작

그러나 atypical loop가 형성된 경우에는 시계반대방향으로 비틀면서

뒤로 빼는 동작이 유용하기도

Hooking the fold (주름걸어 당기기)


N loop of the Sigmoid Colon


Clockwise twist and Withdrawal

Loop of the Sigmoid Colon


N loop (79%/47%) α loop (12%/12%)

reverse α loop (11%/6%)


External compression (복부압박)

Sliding (미끄러져 들어가기)

굴곡이 심한 부위에서 모든 수단을 동원해도 관강이 보이지 않는 경우,

관강이 있을 것으로 생각되는 방향을 정확히 예측할 수 있다면

내시경 선단부를 그 방향으로 굴절시킨 후 관강을 보지 못한 상태에서

내시경을 밀어서 장관 벽을 따라 미꾸러져 들어가기도 한다

.


Take-Home Message

충분한 대장 정결

첫 1-2분이 가장 중요

공기의 주입은 최소한으로

삽입보다는 단축

Torque와 Right turn shortening을 적절히 이용

같은 동작은 3회 이상 반복하지 않기

자세변화와 복부압박을 적절히 이용

Position change (체위변화)

우측와위 : S-자 결장-하행결장 이행부와 비만곡부 통과시

앙와위 : 횡행결장 통과시

좌측와위 : 간만곡부 통과시


빈틈없이 하는 대장내시경


24

Take-Home Message

절 대 무 리 하 지 않 는 다 !!!


Scrutinize : 면밀히 검사하다


Miss rate for colorectal neoplastic polyps : a prospective multicenter study of back to back colonoscopy

Endoscopy 2008; 40: 284-290

Polyp Miss Rates by Tandem Colonoscopy : A systemic review

Rijn J. Am J Gastro 2006;101:343-350


What is optimal withdrawal technique?

Two experienced endoscopists (miss rate 17% vs 48%)

Video-taped 10 consecutive colonoscopic withdrawals- assessed

by 4 experts

Rex DK. Gastrointest Endosc 2000;51:33-36

Criterion 17% 48% p

Looking on the proximal sides of folds 31.5 19.6 <0.001

Adequacy of cleaning 33.1 21.9 <0.001

Adequacy of distention 33.5 24.0 <0.001

Adequacy of time spent viewing 32.4 21.0 <0.001

Miss rate for colorectal neoplastic polys : a prospective multicenter study of back to back colonoscopy

Endoscopy 2008; 40: 284-290


Viewing behind the Fold

대장내시경의 맹점부위


Withdrawal Times and Adenoma Detection during Screening Colonoscopy

N Engl J Med 2006;355:2533-41

Impact of withdrawal speed on polyp yield

Simmons DT, et al. Aliment Pharmacol Ther 2006: 24, 965–971


Modifiable endoscopic factors that influence the adenoma detection rate

Gastrointest Endosc 2013;77:381-9

Long mean withdrawal time is associated with increased adenoma detection

Lee TJ Wet al. Endoscopy 2013; 45: 20–26


Detection of Adenomas in Asymptomatic Individuals

Continuous Quality Improvement Targets

- Adenoma prevalence rates detected during colonoscopy in

persons

undergoing first-time examinations

25% in men older than 50

15% in women older than 50

Rex DK Gastrintest Endosc 2006;63(suppl):S16-S28

NHS BCSP Publication No 6 February 2011

Withdrawal Times

Continuous Quality Improvement Targets

- Mean withdrawal times should average at least 6-10 min.

Mean inspection time ≥ 6 minutes on withdrawal from caecal pole to

anus in negative procedures.

Recommend that the average withdrawal time is audited during

screening colonoscopies and propose a minimum of 6 minutes

in at least 90% of purely diagnostic examinations.

Rex DK (ASGE) Gastrintest Endosc 2006;63(suppl):S16-S28

Rembacken B et al. (ESGE) Endoscopy 2012; 44: 957–968

NHS BCSP Publication No 6 February 2011


Polyp detection rate is improved with position change

East J. GIE 2007;65:263-269

Proposed minimum colonoscopic withdrawal time


East J. GIE 2007;65:263-269



East J. GIE 2007;65:263-269


Wide angle colonoscopy

A. Standard (140 angle of view) B. wide angle (170 angle of view)

Third eye retroscope

Potential methods to improve detection

See behind folds better See flat lesions better

Wide angle colonoscopy Chromoendoscopy

Colonoscopy in retroflexion High definition

Cap-fitted colonoscopy Narrow band image

Third eye retroscope Autofluorescence


The efficacy of cap-assisted colonoscopy in polyp detection and cecal intubation

: a meta-analysis of randomized controlled trials

Am J Gastroenterol 2012; 107:1165– 1173

Forest plot on the proportion of patients with polyps detected.

Cap-fitted colonoscopy

Various imaging colonoscopy

A.White light B. Autofluorescence C. NBI D. Chromoendoscopy


Transparent Cap-Assisted Colonoscopy Versus Standard Adult Colonoscopy

: A Systematic Review and Meta-analysis

Dis Colon Rectum 2012; 55: 218–225

The efficacy of cap-assisted colonoscopy in poly detection and cecal intubation

: a meta-analysis of randomized controlled trials

Am J Gastroenterol 2012; 107:1165– 1173

Forest plot on the proportion of patients with adenomas detected.


Take-Home Message

Looking on the proximal sides of folds

Adequate of cleaning

Adequate of distention : air , position changes

Adequate of time spent viewing

: a minimum of 6 minitues


대장 염증성 병변의 진단

김 영 호


Stomach

Bx : No malignant cell H. pylori-associated

chronic gastritis

Tx : PPI

염증성 장질환

Winter School 2016

성균관대학교 의과대학 삼성서울병원 소화기내과

김영호

6


Today’s Topic

Colonoscopy with biopsy is not enough.

Colon

Bx : No malignant cell, Chromic active inflammation

Tx : Steroid/Mesalazine

PMH : Oral ulcer


Endoscopic Features of UC

Mild

loss of vascular tranasluscency, fine granularity, redness, minute yellow spots

Moderate

coarse mucosal erosions, small ulcers, friability, attachment of mucopurulent exudates

Severe

extensive ulcers, profuse spontaneous bleeding

“Continuous, superficial inflammation from rectum” “confined to rectum and colon”

Ulcerative Colitis

• Bloody diarrhea

• Abdominal pain

• Urgency

• Tenesmus


Endoscopic Findings of Ulcerative Colitis

Endoscopic Findings of Ulcerative Colitis


Histologic Findings of Ulcerative Colitis

Mayo Endoscopic Subscore

Nat Rev Gastroenterol Hepatol 2010;7:15


Hemorrhoids

Differential Diagnosis of Lower Gastrointestinal Bleeding

• Inflammatory bowel disease

• Benign anorectal disease : hemorrhoids, anal fissure, fistula-in-ano, varices

• Neoplasia

• Diverticular disease

• Arteriovenous malformation

• Radiation enterocolitis


Nonspecific Colitis

Hemorrhoids

• Hemorrhoids – bright red blood – not mixed with stool – on the toilet tissue – dripping into the toilet

when straining or at the end of defecation

• Ulcerative colitis - diarrhea

- mucoid stool

- urgency

- tenesmus


Case

• 69 yr old man

• 8 days ago, lower abdominal pain

• 6 days ago, diarrhea with fever

• 3 days ago, hematochezia

• WBC 15240/L, CRP 24.08 g/dL

Nonspecific Colitis


Infectious Colitis

• Symptoms – acute onset – fever, vomiting, abd pain, frequent bowel

movement • Endoscopy

– severe hyperemia, profuse exudate – rectal sparing, patchy distribution

Stool Culture : Shigella sonnei


Infectious Colitis

• Regardless of the etiology, clinical symptoms are quite

similar.

• It is hard to prove the existence of pathogens.

• Patients whose symptoms have not improved within 1

week should undergo a sigmoidoscopy or colonoscopy.

Infectious Colitis

• Pathologic findings suggesting UC

– crypt architecture distortion

– mixed lamina propria cellularity

– basal lymphoid aggregates

– villous surface

– crypt atrophy

– surface erosion


Colonoscopic Findings of Infectious Colitis

• UC (ulcertive colitis)-like

– Shigella, Salmonella, Campylobacter, Amoeba

• CD (Crohn’s disease)-like

– Salmonella, Campylobacter, Yersinia, Amoeba

M/52 • 5 days ago, mild fever, mucoid stool, diarrhea, low abdominal

pain • PMH : Tx with pneumonia 3 weeks ago • C. difficele toxin assay (+)


Salmonellosis

UC-like CD-like

Infectious Colitis

Shigella UC-like

Yersinia CD-like


Case

• 51 yr old man

• Previously healthy

• 1 day ago, sudden onset of abdominal pain, followed by

hematochezia

Amoebic Colitis

UC-like CD-like


Ischemic Colitis

• Old age • Sudden onset of abdominal pain & hemtochezia • Endoscopy

– hyperemia, edema, ulceration – rectal sparing – resolved within 1-2 weeks – Bx : coagulation necrosis


Case

• 29 yr old female

• 2001.1. cervix ca -> radiation + chemotherapy

• 2001.8. hematochezia


Radiation Colitis Vienna Rectoscopy Score

• Telangiectasia: Grade 0: none; Grade 1: single telangiectasia; Grade 2: multiple non-confluent telangiectasia; Grade 3: multiple confluent telangiectasia

• Congested mucosa: Grade 0: none; Grade 1: focal reddening of the mucosa combined with edematous mucosa; Grade 2: diffuse non-confluent reddening of the mucosa combined with edematous mucosa; Grade 3: diffuse con-fluent reddening of the mucosa combined with edematous mucosa

• Ulceration: Grade 0: none; Grade 1: micro-ulceration with or without superficial < 1 cm2; Grade 2: superficial > 1 cm2; Grade 3: deep ulceration; Grade 4: fistula, perforation

• Stricture: Grade 0: none; Grade 1: more than two-thirds of the regular diameter; Grade 2: One-third to two-third of the regular diameter; Grade 3: less than one-third of the regular diameter; Grade 4: complete obstruction

• Necrosis: Grade 0: none; Grade 1: necrosis

• Types of mucosal reactions were then subsumed according to the Vienna Rectoscopy Score (Score 0–5; Table 1).

Wachter S et al. Radiother Oncol 2000;54:11

Radiation Colitis

• Radiation history due to cervix ca or prostatic ca

• Endoscopy

– proximal rectum & distal sigmoid colon

– mucosal friability

– granularity with spontaneous bleeding

– multiple telangiectasia



• 10 years ago, constipation with straining

• Anal bleeding, mucoid stool, tenesmus, lower

abdominal pain

Case

Radiation Colitis Vienna Rectoscopy Score

Wachter S et al. Radiother Oncol 2000;54:11


Defecography

Colonoscopy

Colonoscopic Biopsy : Tubular Adenoma with Erosion


Solitary Rectal Ulcer Syndrome

• Histology – characteristic – obliteration of lamina propria by fibromuscular

proliferation of the muscularis mucosa – streaming of fibroblasts and muscle fibers up between

crypts – thickening of muscularis mucosa – branching, distorted glandular crypts – diffuse collagen infiltration of lamina propria

Solitary Rectal Ulcer Syndrome

• A chronic course characterized by rectal bleeding, disordered

defecation, tenesmus and mucorrhea

• Endoscopy

– anterior wall, 4 to 15 cm from the anal verge

– shallow ulcers with white, sloughy base surrounded by a

thin rim of erythematous mucosa


Case


• 2001.9. hematochezia -> sigmoidoscopy

– Diagnosed as ulcerative proctitis

• Maintenance with 5-ASA suppository

• 2003.1. RLQ pain -> colonoscopy

Skip ? Patchy ? Rectal Sparing ?

Endoscopic Findings

Ulcerative colitis Crohn’s disease

Ractal sparing rarely frequently

Continuous disease yes occasionally

Cobblestone no yes

Granulaoma on biopsy no occasionally


Crohn’s Disease

• Aphthous ulcer • Longitudinal ulcer • Cobblestone appearance

“Discontinuous, transmural inflammation from esophagus to rectum”


Crohn’s Disease Endoscopic Index of Severity

크론병 진단기준개정안 (일본후생청, 1995)



Crohn’s Disease


Crohn’s Disease

Crohn’s Disease


Tuberculous Colitis

Tuberculous Colitis


Prospective Evaluation of the Clinical Utility of Interferon-ɣ Assay in the Differential Diagnosis of ITB & CD

Kim BJ et al, Inflamm Bowel Dis 2011;17:1308

결핵성 장염_조직 검사

• 어디서 ? – 균배양 : 궤양 저부 – 건락성 육아종 : 궤양 저부와 변연부

• 크론병과 다른 점 – AFB +, Caseating granuloma + – 육아종이 많고 크다. – 육안적으로 정상인 부위에서 조직 검사를 하면 정상 소견이다.


Case

• Male, 34 years old • Abdominal pain, diarrhea & weight less (5 Kg) for 2 months • Past history of anal fistula

• CRP 9.67 mg/dL

Diagnosis of Tuberculous Colitis_Korean Guideline


Case

• Colonoscopic biopsy – focal active inflammation with non-caseating granuloma – AFB smear (-) – M. tuberculosis PCR (-)

• Tuberculin skin test (-)

Case

• Focal active inflammation with non-caseating granulomas and erosions

• AFB (1+) 1-9/100HPF


Tuberculous Colitis

Case • Therapeutic trial with anti-TB medication • Colonoscopy F/U 2 mo later


Behçet’s Disease

Intestinal Tuberculosis vs Crohn’s Disease

Lee YJ, et al. Endoscopy 2006;38:592

Characteristic of Tb Involvement of fewer than 4 segments A patulous IC valve Transverse ulcers Scars or pseudopolyps

Characteristic of CD Anorectal lesions Longitudinal ulcers Aphthous ulcers Cobblestone appearance

PPV for CD : 94.9% PPV for TB : 88.9%


Behçet’s Disease

Lee CR, et al. Inflammatory Bowel Disease 2001;7:243

Behçet’s Disease


Behçet’s Disease

Behçet’s Disease

Typical colonoscopic finding ;

Single or a few deep round/oval ulcers with discrete

margin in ileocecal area


M/52 • Low abdominal discomfort

Bx : focal active inflammation, terminal ileum

Lee SK et al, Endoscopy 2009;41:9

Sensitivity 94.3% Specificity 90.0%

Differential Diagnosis of Crohn’s Disease & BD by Colonscopic Findings


F/24 • 2개월 전 외부 병원에서 건강 검진으로 대장내시경 시행

M/52 • Diarrhea (-) Hematochezia (-) Wt loss (-) Oral ulcer (-)

• ESR/CRP : normal

• “복통이나 설사가 심해지거나 혈변이 생기면 들리세요”

Colonoscopy, 1 year later


Conclusion

Colonoscopy with biopsy is not enough.

F/24 • 현재 특이 증상 없음 • 건강 검진 1주일전 발열, 복통, 설사

Colonoscopy 6 mo later


대장 종양성 병변의 진단과 치료

장 동 경


Colon Polyps (Epithelial origin)

Neoplastic Non-neoplastic

Premalignant polyp Mucosal tagTubular adenoma HyperplasticTubulovillous adenoma InflammatoryVillous adenoma Juvenile

Carcinoma in situ: D01.0~01.2 (by 2010 AJCC staging)High-grade dysplasiaIntraepithelial cancer (CIS)Intramucosal cancer (infiltrating into lamina propria)

Invasive carcinoma: C18 ~20Submucosal cancer (Malignant polyp) –beyond the m.m.

Sungkyunkwan University, School of MedicineSamsung Medical Center

Dong Kyung Chang

2016 Winter School

대장 종양성 병변의 진단과 치료


Adenomatous Polyp

Ip Isp Is

0.2 cm

IIa

Paris endoscopy classification for superficial (type 0) lesions (tumors with superficial invasion:M,SM)

*Protruding lesions are elevated more than 2.5 mm.

Ip


Classification of LSTs

LST-G (granular) 46%

LST-NG (non-granular) 54%

Kudo: LST-G-H (homogeneous)Paris: IIa 30%

LST-G-M (nodular mixed)IIa + Is 16%

Kudo: LST-NG-F(flat elevated)Paris: IIa 41%

LST-NG-PD (pseudodepressed)IIc + IIa, IIa + IIc 13%

Kudo S. 1993Kudo S et al. Stomach and Intestine. 2005. 40;1367Kudo S et al. Gastrointest Endosc 2008;68(S4):S3

LST: Lateral spreading tumor (> 1cm)

G-H (Granular type – Homogeneous) NG-F (flat elevated)


Multifocal submucosa-invading cancer

LST-G: 1/7 (14.3%)LST-NG: 5/20 (25.0%)

Shinji Tanaka 2006. Basic Technique of EMR and ESD for colorectal tumors

LST-GLST-G-H M 22.9 13.5 39.5

SM 1.8 1.0 3.4LST-G-M M 33.5 25.4 38.0

SM 18.0 5.1 25.0

LST-NGLST-NG-F M 12.7 11.3 17.9

SM 4.1 1.9 11.9LST-NG-PD M 23.5 19.6 31.8

SM 25.0 15.2 45.5

M/SM total (%) < 2 cm(%) > 2 cm(%)

Proportion of M/SM cancers according to the type and the size of the LST

Yamano H et al. Stomach and Intestine. 2007.


Rectal LST-G-M, 5 cm

Adenocarcinoma, (well differentiated) in the pre-existing adenoma

Adenoma size: 5.0 x 4.5 cmCancer Size: 0.4 x 0.2 cm

Depth of invasion: intraepithelial carcinoma(pTis)

LST-G-MN type

An invasive cancer focus in the large nodule


Hyperplastic Polyp

Neoplastic vs. Non-neoplastic

Neoplastic : benign vs. malignant

Malignant : mucosal vs. submucosal or deeper

Three steps to observe polyps for treatment plan

Methods:

Gross endoscopic appearance

Vascular pattern analysis

Pit pattern analysis etc.


Inflammatory polyp

Tuberculosis scar

Cecum

Ascending colon

Inflammatory polyp

Ulcerative colitis

Ascending colon

Sigmoid colon


Cecal fold thickening ? tubular adenoma

Adenomatous

Polyp

Hyperplastic

Polyp


Serrated Adenoma, ascending colon

염증? Tubular adenoma with High grade dysplasia!


Endoscopic Appearance of Depressed type Early Colon Cancers

Color change: hyperemic,

rarely whitish (ddx. with hyperplastic polyp)

Spontaneous bleeding, or bleeding induced by air-inflation

Wall deformity

Irregular-edged depression

Early colon cancer: IIc+IIa

de-novo cancer ?


Increased air volume Decreased air volume

Air-induced deformity in M/SM1 cancer

Gross Endoscopic Appearances suggestive ofMassive Malignant Submucosal Invasion

Size & Gross type: depressed >1 cm, flat or superficial elevated > 2 cm, protruded or LST > 3 cm

Hardness, stiffness, or rigiditySevere depression, erosion, or ulcerPolyp on polyp (Buddha) appearanceFold convergenceLoss of air-induced deformityPit pattern : type Vn (nonstructural)

Non-lifting sign


Adenocarcinoma, W/D- extension to submucosa

Fold convergence, Polyp on polyp appearance…

Adenocarcinoma, W/D- extension to the Muscularis Propria

Hardness, non-lifting…


바늘이 고유근층을 뚫으면 융기되지 않는다. cf) Non-lifting sign (+)인 경우: 주위 점막은 잘 융기.

Fold convergence, hardness, erosions,

Loss of air-induced deformity, non-lifting…

Adenocarcinoma, W/D- extension to submucosa


Pit Pattern Classification & Treatment

I: normal II: stellate

IIIL : large tubular IIIS :small round

VI : irregular VN : non-structural

IV: branched, gyriform

Kudo S et al, Endosccopy 2001;33:367

Non-neoplastic : No treatment

Adenoma: Endoscopicresection

SM Cancer: Surgery

Cancer: Endoscopic resection(en bloc)

Do not try submucosal injection if you are not prepared to do complete resection!

D0 D7Fibrosis 생겨서 en bloc resection 안 됨.

-> Piecemeal EMR과 coagulation으로 제거

LST는 ESD를고려하는경우라면 biopsy도 1 – 2 개만가볍게!!


NBI international colorectal endoscopic (NICE) classification

Tanaka S, Sano Y. Dig Endosc. 2011 May;23 Suppl 1:131-9

EndoscopicResection

SurgeryNo treatmentor Endoscopic Resection

NBI – Vascular pattern: Sano classification

Tanaka S, Sano Y. Dig Endosc. 2011 May;23 Suppl 1:131-9


Hyperplastic polyp, ascending colon

Sungkyunkwan University, School of MedicineSamsung Medical Center

Dong Kyung Chang

Serrated Polyps


Sessile Serrated Adenoma, ascending colon

Sessile Serrated Adenoma, ascending colon


Study Data source Total detected cancers, n

Interval cancers

Overall, n (%)

Proximal, n (%)

Distal, n (%)

Baxter et al2011

Ontario Ca Registry (2000–2005) 34,312 1260 (9.0) 676 (12.4) 584 (6.8)

Singh et al2010

Manitoba Ca Registry(1992–2008) 4883 388 (7.9) 225 (11.3) 147 (5.3)

Cooper et al 2012

SEER-Medicare DB (1994–2005) 57,839 4192 (7.2) 2851 (9.9) 1253 (4.5)

Frequency and Location of Interval CRCs

Patel SG, Ahnen DJ. Clinical Gastroenterology and Hepatology 2014; 12:7-15

Colonoscopies have resulted in an overall reduction of

-CRC-related deaths by 29%-Deaths from distal CRC by 47%

-No observed reduction in deaths caused by proximal CRC

* More right-sided CRC cases in the setting of previousnegative colonoscopic examinations (interval carcinomas)

PROBLEM POSING

Singh H, Nugent Z, Demers AA, et al. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology 2010;139:1128-37


• Serrated = saw-tooth like

• 36% of colonic polyps

• Past: Hyperplastic polyp - the only recognized serrated polyp

• A heterogeneous family of polyps

- Hyperplastic polyp

- Sessile Serrated adenoma/polyp

- Traditional Serrated adenoma

SERRATED POLYPS

Pabby et al21 and Robertson et al37

•50% - 75% of interval CRCs : missed or incompletely resected lesions•less than 30% : rapidly progressing lesions.

Missed LesionsAdenoma detection rates (ADRs) : 17 – 47% (serrated polyps : 1 – 18%)Tandem colonoscopy (van Rijn et al 2006)/colonoscopy in tandem with CT colonography (Pickhardt et al 2003)

overall adenoma miss rate : 22%, miss rate for adenomas of 10 mm or greater : 2% - 12%

Incomplete PolypectomyOverall incomplete resection rate: 10.1% (6.5%–22.7%) (Pohl et al 2013)

- Larger polyps :5.8% (for 5-7mm) vs 23.3% (for 15- 20 mm)- Sessile serrated polyps (vs adenomas): 31% vs 7.2%

Rapid ProgressionLynch syndrome MSI, CIMP, and lower rates of KRAS mutations serrated polyp pathwaySessile serrated polyps : common in the right colon, missed frequently during endoscopy, and a higher rate of incomplete resection.42

Etiology of Interval Colorectal Cancers

Patel SG, Ahnen DJ. Clinical Gastroenterology and Hepatology 2014; 12:7-15


Hyperplastic polyp (Microvesicular type)

GASTROINTESTINAL ENDOSCOPY 2013:77(3);360 -375

Normal colon



- 5% (1 ~ 9%) of all colonic polyps

- median 62years, 50 – 65% in women

Sessile Serrated Adenoma/Polyp (SSA/P)

Sessile serrated adenoma/polyp (SSA/P)



Histological features- serrations in the whole length of crypts- boot-, inverted T- shaped, horizontally oriented crypt bases- tends to lack both a thickened subepithelial collagen table and

a prominence of neuroendocrine cells

Recent expert consensus opinions have simplified thediagnostic difficulties:

First, a single crypt with unequivocal dilation, distortion, and/orhorizontally branched crypt is sufficient to establish a dx of SSA/P

Second, clinicians are advised to manage any hyperplasticpolyp >10 mm proximal to the sigmoid as an SSA/P.

SSA/P

Endoscopic features

- predilection for the right colon- flat or sessile- usually > 5 mm- tends to be redder than the other serrated polyps,

(less red than the conventional adenomas)- a yellow-tinged mucus cap, a rim of debris or bubbles,alteration of mucosal fold contour, indistinct borders, andobscuring of submucosal vasculature

“SSA/P is typically flat with indistinct borders, makingrecognition and complete excision challenging.”

Pit pattern : type II open–shape pit pattern (type II-O)- represent dilated crypt bases (wider and rounder)

SSA/P


- Precancerous lesion as itself

- A greater polyp burden, and synchronous and metachronousneoplastic lesions

“Identification of SSA/Ps requires increased vigilance for lesions elsewhere in the colon”

- Common cause of interval cancer

* Interval cancer- Missed precursor lesions- Incomplete subtotal polyp resection- Rapidly growing precursor lesions Small, flat, indistinct-bordered, and right-sided polyps (suchas SSA/Ps) are a high risk of interval cancer

Clinical significance of SSA/P

Nomenclature

Why SSA/P? (SSA = SSP)

The term “adenoma” historically implied low-grade dysplasia

SSA/P without cytologic dysplasia lacks the cytologic featurestypically seen in low-grade dysplasia in the tubular adenoma

- “sessile serrated polyp” : no or serrated dysplasia(not conventional dysplasia)

- “sessile serrated adenoma” : malignant potential


Traditional serrated adenoma, Descending colon

- TSA was introduced in 1990- < 1% of all colonic polyps

Endoscopically,- usually left-side predominant,- pedunculated or sub-pedunculated- usually > 5 mm- granulonodular and lobular appearance (like

conventional adenoma)

Pit pattern:often combined pit patterns: type II and/or IIIS/IIIL(not common in the conventional adenoma)

Traditional serrated adenoma (TSA)


Sessile serrated neoplastic pathway


MOLECULAR ASPECTS OF THE SERRATED NEOPLASTIC PATHWAY

Molecular genetics of CRC - 3 most established pathways

(1) Chromosome instability pathway: APC, K-RAS-P53

(2) DNA mismatch repair pathway:

MMR(MSH2, MLH1, MSH6, PMS2) MSI

(3) CpG island hypermethylation (CIMP) pathway the

central defect of the serrated pathway of neoplasia.


- 1.8 – 4 % of colonoscopy patients

- Median ages: 50 – 62 years

- Up to nearly 40% risk of CRC

A study of 4,462 polyps from 100 pts with serrated polyposis- 83% were serrated polyps

(156 MVHPs, 25 GCHPs, 138 SSAs, 18 TSAs)- 17% were conventional adenomas

(55 tubular adenomas, 14 tubulovillous adenomas).

Serrated polyposis

Serrated polyposis (formerly, hyperplastic polyposis)

WHO criteria for serrated polyposis

- At least 5 serrated polyps proximal to the sigmoid colon,at least 2 polyps 10 mm, or

- Any number of serrated polyps proximal to the sigmoidcolon in an individual who has a first-degree relative withserrated polyposis, or

- 20 serrated polyps of any size distributed throughoutthe colon


Management of Serrated Polyposis

All proximal colon polyps or all serrated polyps > 5 mmshould be completely removed, if numerous diminutivepolyps are observed.

Colon resection can be advised for colorectal cancer orwhen endoscopic control of polyps is no longer feasible.

Given the malignant potential of the SSA/P, TSA, and filiformSA, complete endoscopic resection is critical.

- All proximal serrated polyps (proximal to the sigmoidcolon) should be removed

- All proximal serrated polyps > 10 mm diagnosed ashyperplastic polyps should be clinically managed as SSA/Ps

When SSA/P margins cannot be fully resected, residualtissue can be removed by cold forceps or burned by APC,and close endoscopic follow-up is advised- 1 year per the U.S. Multi-Society Task Force guidelines- 3 ~ 6 months per expert consensus opinions

CLINICAL MANAGEMENT RECOMMENDATIONS


Natural History of Untreated Polyp

• A study using serial sigmoidoscopy for tattooed colorectal polyps < 1 cm(not all of which would have been adenomas) over the course of 3 to 5 years

– 4% increased in size – 70% remained unchanged – 8% were smaller– 18% disappeared

• A diminutive adenoma(<0.5 cm) requires 2 to 3 years to reach 1 cm size

Kozuka S. Dis Colon Rectum 1975

대장용종조직검사 vs. 용종제거술


Surgical polypectomies Colonoscopic polypectomiesAdenoma Size

<1cm 1.3% 0.5%1-2cm 9.5% 4.6%>2cm 46.0% 10.8%

Histologic Typetubular 4.8% 2.8%villotubular 22.5% 8.4%villous 40.7% 9.5%

Degree of dysplasiamild 5.7% 2.8%moderate 18.0% 8.4%severe 34.5% 9.5%

Percentage of containing cancer in adenoma

Muto T. Cancer 1975

Cumulative risk for cancer in 1cm adenoma

- 2.5% at 5 yrs, - 8% at 10 yrs, - 25% at 20 yrs

Carroll RLA Prev Med 1980


Incidence/mortality of CRC and screening uptake rates over time (US)

Source: Clinical Gastroenterology and Hepatology 2014; 12:7-15 (DOI:10.1016/j.cgh.2013.04.027 ) Copyright © 2014 AGA Institute

Winawer, S. J. et al. N Engl J Med 1993;329:1977-1981

Cumulative Incidence of Colorectal Cancer in the National Polyp Study Cohort

- 76 ~ 90 % reduction in cancer incidence -


• Two-stage polypectomy에서 조직 결과 불일치율: 15 – 30 %

• 대장 용종의 60 – 70 %가 선종: 결국 다수에서 용종제거 필요

• 미소대장암에서 겸자 생검이 조직 구조를 파괴하여 다음의EMR을 곤란하게 할 수 있다.

• Second-stage 에서 용종을 찾지 못하는 경우가 적지 않다.

:생검 결과가 암인데, 찾을 수 없다면 심각한 낭패

• One-stage polypectomy: 환자의 불편, 시간-경제적 손실 감소

One-stage polypectomy의 장점

용종의 최종 진단은 조직학적 검사 필요.

• 겸자 생검 후, 종양성 용종만 제거할 것인가?: Two-stage polypectomy

• 발견 즉시 제거할 것인가? : One-stage polypectomy


그렇다면, 용종을 모두 one-stage로 제거할 것인가?

Rex RK. et al. Quality indicators for colonoscopy.Gastrointestinal endoscopy 63:4;S16 -S28: 2006

• Consistent referral of small “routine” colorectal polyps identified during diagnostic colonoscopy for repeat colonoscopy and polypectomy by others is unacceptable.

• Referral of technically difficult polyps to more experienced endoscopists for endoscopic resection is encouraged.


Rectosigmoid area의 명백한 multiple hyperplastic Polyps

불필요한 용종 제거는 하지 말자

명백한 Inflammatory Polyps

불필요한 용종 제거는 하지 말자


내시경으로 제거해서는 안 되는 용종도 있다.

:내시경으로 완치 불가능한 악성 용종

• 림프절 전이

• 원격 전이

Biopsy only!

점막하층 암세포 대량 침윤-> 림프절 전이율 10 %

“점막하 대량 침윤이 강력히 의심되면, 내시경 절제하지 말자”

자신이 없으면 제거하지 말자 Biopsy only!

기술적 한계 : Endoscopist-dependent

• 절제가 어려운 위치에 있는 용종

:간만곡부 원위부 내측, 비만곡부 원위부 하방, 경사진 위치 등. -> 시야 확보 곤란, 올가미 접근 곤란

• 너무 큰 용종

• 편평형 또는 함몰형으로 완전 절제가 어려운 용종

: Two-stage polypectomy or Surgery


Clinical Significance of Small Colorectal Polyps

High risk adenomas (Atkin et al. 1992. NEJM 326: 658)those containing >25 percent villous architecture, those with severe dysplasia, and those over 10 mm in size.

2,066 (49) 2,002 51 2

418 (67) 359 50 4

496 (77) 235 211 26

<6 4,381

6 - 10 666

>10 675

Total 5,722 2,980 (54) 2,596 312 32

2 (0.1)

1 (0.2)

21(4.2)

24 (0.8)

39

15

89

143

Neoplastic (%)

TA TVA VASize (mm)

n Cancer (% Neoplastic)

Severe dysplasia

4.4%

15.6%

100%

High Risk

Church JM 2004. Dis Colon Rectum 47:481

적어도선종은크기와상관없이제거하는것을권장.

Diminutive polyp (<5 mm)의 절제는 필요한가, 불필요한가?

Risk vs. Benefit


Independent risk factors for failed endotherapy

Feature Statistical association (n=479)Previous intervention OR: 3.75; 95% CI 1.77 to 7.94; p=0.001Ileocaecal valve involvement OR=3.38; 95% CI 1.20 to 9.52; p=0.021Difficult position OR=2.17; 95% CI 1.14 to 4.12; p=0.019Lesion size >40 mm OR=4.37; 95% CI 2.43 to 7.88; p<0.001Previous APC use OR=3.51; 95% CI 1.69 to 7.27; p=0.001

APC, argon plasma coagulation.

Rutter MD et al. British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut. 2015; 64(12): 1847–1873. Moss A, Bourke MJ, Williams SJ, et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011;140:1909–18.

• Endoscopic differential diagnosis for polyps has limitations• Tissue diagnosis is mandatory for confirmation• Symptomatic polyps should be removed.• Neoplastic polyps should be removed.• Asymptomatic, definite non-neoplastic polyps can be followed-up.• Removal of diminutive polyps: controversial ->cold biopsy or snaring• If prepared, one-stage polypectomy is desirable.• Malignant polyps that are highly suggestive of massive submucosal invasion

should be surgically removed. (Non-lifting sign)• Safe endoscopy skill provides wide range of management options.

(One-stage polypectomy, two-stage polypectomy, or surgery)

Summary: Tips for polyp treatment


Non-pedunculated colorectal polyps

Rutter MD et al. British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelinesfor the management of large non-pedunculated colorectal polyps. Gut. 2015; 64(12): 1847–1873.

Major histopathological considerations in the management of large non-pedunculated colorectal polyps (LNPCPs).



Endoscopic management



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