University of Connecticut WEATOGUE, CT, United States
Award: Presidential Poster Award
Alla Turshudzhyan, DO1, Micheal Tadros, MD, MPH, FACG2 1University of Connecticut, Weatogue, CT; 2Albany Medical College, Albany, NY
Introduction: A thorough endoscopy should entail a complete exam of the anal canal, colon and terminal ileum (colonoscopy) as well as esophagus, stomach and proximal duodenum (EGD). Lesions can be missed because of a rushed exam that bypasses a proper visualization of the scope’s entry and exit points, poor bowel preparation, or not taking endoscopic exam to completion and not visualizing all bowel segments. We are going to present 4 cases that resulted in lesions missed or nearly missed.
Case Description/Methods: 72-year-old male presented with symptoms of dysphagia. He had an EGD done, which was unrevealing. It was only after the second EGD that a flat squamous cell carcinoma was appreciated 2 cm below the UES (Fig. 1a). It was missed on the initial scope insertion and could have been easily missed on a rapid scope withdrawal.
40-year-old female presented with iron deficiency anemia requiring multiple transfusions. Multiple upper and lower endoscopies were unrevealing, including a capsule study. It was only after the 4th portion of the duodenum was examined that a malignant GIST was diagnosed and resected (Fig. 1b). Many EGDs do not go past the 2nd part of the duodenum.
50-year-old female presented with ongoing diarrhea. Stool studies revealed cryptosporidium. Fortunately, the patient’s colonoscopy included a terminal ileum and helped detect a small submucosal carcinoid tumor (Fig. 1c). It was successfully resected with metastatic disease noted in one lymph node. Many colonoscopies do not include terminal ileum.
68-year-old female with a history of cirrhosis and recurrent BRBPR. She had 2 colonoscopies done, both of which were unremarkable. It was months later that the patient had a 2 cm anal growth examined and diagnosed on careful retroflexion (Fig. 1d). The lesion was then seen on careful re-inspection of the anal area.
Discussion: Endoscopies are great at detecting lesions but are not perfect. These cases shed light on the importance of thorough endoscopy, which includes distal duodenum and terminal ileum, and careful inspection of scope’s entry and exit points. The 1st patient had a lesion that was challenging to visualize because it was flat and just below the UES. The 2nd patient had the ileum examined, which is not routinely done, and had a timely carcinoid tumor resection. The 3rd patient had an anal lesion that could’ve been easily visualized on exam but was missed on scope insertion. The last patient had the distal duodenum examined identifying a GIST, which is also not routinely done.
Figure: A. subtle flat squamous cell carcinoma was appreciated 2 cm below the upper esophageal sphincter. B. malignant gastrointestinal stromal tumor (GIST) treated with hemospray in distal duodenum/proximal jejunum. C. small submucosal carcinoid tumor in terminal ileum. D. 2 cm anal squamous cell cancer noted on rectal exam.
Alla Turshudzhyan indicated no relevant financial relationships.
Micheal Tadros indicated no relevant financial relationships.
Alla Turshudzhyan, DO1, Micheal Tadros, MD, MPH, FACG2. P1511 - Lessons Learned: Misses and Near-Misses of Endoscopy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.