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Competing Interests: Disclosure All authors disclosed no financial relationships. Commentary During colonoscopy, most endoscopists expect to find 1 of the 5 most common types of colon polyps: tubular adenoma, villous adenoma, serrated adenoma, hyperplastic lesion, or inflammatory lesion. However, less common lesions also occur within the GI system, including lipoma, GI stromal tumors, carcinoids, and sarcomas, among others. Here the authors present the case of a mature teratoma with visible hair, removed by snare polypectomy. This demonstrates that endoscopists can successfully manage unexpected lesions by using minimally invasive techniques. Monica Saumoy, MD, MS, Center for Digestive Health, Penn Medicine Princeton Health, Philadelphia, Pennsylvania, USA Amy Tyberg, MD, FASGE, FACG, Associate Editor for Focal Points

Objectives: First, to investigate the accuracy of transvaginal sonography (TVS) for presurgical evaluation of the distance between the most caudal part of the endometriotic lesion and the anal verge (lesion-to-anal-verge distance (LAVD)) in women with rectosigmoid deep endometriosis (DE), compared with intraoperative measurement (IOM). Second, to assess the agreement between anastomosis height and LAVD measured using TVS., Methods: This was a prospective observational multicenter study of symptomatic women who were scheduled for surgical treatment of rectosigmoid DE, by either discoid or segmental resection, between April 2017 and September 2019. Presurgical TVS was performed to evaluate the LAVD in two ways, depending on the level of the lesion. Method 1: for lesions at the level of the rectovaginal septum (RVS), the caudal part of the lesion was identified on TVS and an index finger was placed on the TVS probe at the level of the anal verge. The probe was withdrawn and the distance from the tip of the TVS probe down to the index finger was measured using a ruler, representing the LAVD. Method 2: for lesions above the RVS, the distance between the caudal part of the lesion and the lower lip of the posterior cervix was measured in a frozen image (LAVD-1), and the distance between the lower lip of the posterior cervix and the anal verge (LAVD-2) was measured using Method 1. These two measurements (LAVD-1 and LAVD-2) were added together and the result represented the total LAVD. During surgery, a rectal probe was used to perform IOM of LAVD, which was considered as the gold standard test. Agreement between LAVD measured using TVS and the IOM was assessed using Bland-Altman analysis. The intraclass correlation coefficient (ICC) for absolute agreement and Spearman's correlation coefficient were also calculated. Systematic and proportional bias were tested for significance using the paired t-test. Similar analysis was performed to assess agreement between LAVD measured using TVS and anastomosis height., Results: A total of 147 consecutive women were considered eligible for inclusion. Fourteen women were excluded initially. Thirty-four discoid resections and 102 segmental resections were performed; both procedures were performed in three women. Two more women were excluded from the final analysis because the measurements represented extreme outliers. The mean LAVD measured using TVS was 114.8 ± 36.5 mm and the mean IOM was 116.9 ± 42.3 mm. There was no statistically significant difference between LAVD measured using TVS and IOM (mean difference, -2.12 mm (95% CI, -6.33 to 2.05 mm); P = 0.32). Bland-Altman analysis showed that there was good agreement between the two methods. The ICC was 0.81 (95% CI, 0.74-0.86) and Spearman's correlation coefficient was 0.68 (95% CI, 0.56-0.77). The mean difference between LAVD measured using TVS and anastomosis height was statistically, but not clinically, significant (mean difference, 10.25 mm (95% CI, 5.94-14.32 mm); P = 0.0005), and the ICC was 0.78 (95% CI, 0.66-0.85)., Conclusions: There is good agreement between the LAVD measured using TVS and the IOM in women with rectosigmoid DE. As a consequence, TVS could be useful for estimation of the height of the final surgical anastomosis in women undergoing full-thickness resection for rectosigmoid DE. This is of pivotal importance in reducing the risk of complications and need for a temporary stoma, and could improve patient counseling. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology., (© 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.)

Background: Operative approaches for Hinchey III diverticulitis include the Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage. Several randomized controlled trials and meta-analyses have compared these approaches; however, results are conflicting and previous studies have not captured the complexity of balancing surgical risks and quality of life., Objective: This study aimed to determine the optimal operative strategy for patients with Hinchey III sigmoid diverticulitis., Design: We developed a Markov cohort model, incorporating perioperative morbidity/mortality, emergency and elective reoperations, and quality-of-life weights. We derived model parameters from systematic reviews and meta-analyses, where possible. We performed a second-order Monte Carlo probabilistic sensitivity analysis to account for joint uncertainty in model parameters., Setting: This study measured outcomes over patients' lifetime horizon., Patients: The base case was a simulated cohort of 65-year-old patients with Hinchey III diverticulitis. A scenario simulating a cohort of highly comorbid 80-year-old patients was also planned., Interventions: Hartmann procedure, primary resection and anastomosis (with or without diverting ileostomy), and laparoscopic lavage were performed., Main Outcome Measures: Quality-adjusted life years were the primary outcome measured., Results: Following surgery for Hinchey III diverticulitis, 39.5% of patients who underwent the Hartmann procedure, 14.3% of patients who underwent laparoscopic lavage, and 16.7% of patients who underwent primary resection and anastomosis had a stoma at 12 months. After applying quality-of-life weights, primary resection and anastomosis was the optimal operative strategy, yielding 18.0 quality-adjusted life years; laparoscopic lavage and the Hartmann procedure yielded 9.6 and 13.7 fewer quality-adjusted life months. A scenario analysis for elderly, highly comorbid patients could not be performed because of a lack of high-quality evidence to inform model parameters., Limitations: This model required assumptions about the long-term postoperative course of patients who underwent laparoscopic lavage because few long-term data for this group have been published., Conclusions: Although the Hartmann procedure is widely used for Hinchey III diverticulitis, when considering both surgical risks and quality of life, both laparoscopic lavage and primary resection and anastomosis provide greater quality-adjusted life years for patients with Hinchey III diverticulitis, and primary resection and anastomosis appears to be the optimal approach. See Video Abstract at http://links.lww.com/DCR/B223. ESTRATEGIA OPERATIVA ÓPTIMA EN DIVERTICULITIS HINCHEY III DE SIGMOIDES: UN ANÁLISIS DE DECISION: Los enfoques quirúrgicos para la diverticulitis Hinchey III incluyen el procedimiento de Hartmann, la resección primaria y anastomosis, y el lavado laparoscópico. Varios ensayos controlados aleatorios y metanálisis han comparado estos enfoques; sin embargo, los resultados son contradictorios y los estudios previos no han captado la complejidad de equilibrar los riesgos quirúrgicos y la calidad de vida.Determinar la estrategia operativa óptima para pacientes con diverticulitis Hinchey III de sigmoides.Desarrollamos un modelo de cohorte de Markov, incorporando morbilidad / mortalidad perioperatoria, reoperaciones electivas y de emergencia, y pesos de calidad de vida. Derivamos los parámetros del modelo de revisiones sistemáticas y metaanálisis, cuando fue posible. Realizamos un análisis de sensibilidad probabilístico Monte Carlo de segundo orden para tener en cuenta la incertidumbre conjunta en los parámetros del modelo.Seguimiento de por vida.El caso base fue una cohorte simulada de pacientes de 65 años con diverticulitis de Hinchey III. También se planeó un escenario que simulaba una cohorte de pacientes de 80 años altamente comórbidos.Procedimiento de Hartmann, resección primaria y anastomosis (con o sin desviación de ileostomía) y lavado laparoscópico.Años de vida ajustados por calidad.Después de la cirugía para la diverticulitis de Hinchey III, el 39.5% de los pacientes que se sometieron al procedimiento de Hartmann, el 14.3% de los pacientes que se sometieron a un lavado laparoscópico, y el 16.7% de los pacientes que se sometieron a resección primaria y anastomosis tuvieron un estoma a los 12 meses. Después de aplicar el peso de la calidad de vida, la resección primaria y la anastomosis fueron la estrategia operativa óptima, que dio como resultado 18.0 años de vida ajustados en función de la calidad; el lavado laparoscópico y el procedimiento de Hartmann arrojaron 9.6 y 13.7 meses de vida ajustados en función de la calidad, respectivamente. No se pudo realizar un análisis de escenarios para pacientes de edad avanzada altamente comórbidos debido a la falta de evidencia de alta calidad para informar los parámetros del modelo.Este modelo requirió suposiciones sobre el curso postoperatorio a largo plazo de pacientes que se sometieron a lavado laparoscópico, ya que se han publicado pocos datos a largo plazo para este grupo.Aunque el procedimiento de Hartmann se usa ampliamente para la diverticulitis de Hinchey III, cuando se consideran tanto los riesgos quirúrgicos como la calidad de vida, tanto el lavado laparoscópico como la resección primaria y la anastomosis proporcionan una mayor calidad de años de vida ajustada para los pacientes con diverticulitis de Hinchey III y la resección primaria y anastomosis parece ser el enfoque óptimo. Consulte Video Resumen en http://links.lww.com/DCR/B223.

Background: Female genital tuberculosis (FGTB) is a form of extra pulmonary tuberculosis (EPTB) affecting women of reproductive age group. It causes significant morbidity in women especially infertility particularly in developing countries. Diagnosis is by endometrial sampling for acid fast bacilli (AFB) microscopy, culture, gene Xpert, polymerase chain reaction (PCR), histopathological evidence of epithelioid granuloma and by laparoscopic findings suggestive of tuberculosis., Aim: Present study was conducted to observe the prevalence of a new "Sharma's Sigmoid colonic adhesive band "in FGTB on laparoscopy., Methods: It was a prospective study in a tertiary referral center as a part of our ongoing tuberculosis project on 148 infertile women found to have FGTB on microbiological or laparoscopic findings over previous 10 years. A new laparoscopic "Sharma's Sigmoid colonic adhesive band" was looked for in these cases on laparoscopy., Results: The mean age, parity and duration of infertility and incidence of poor socioeconomic status was 26.9 years, 0.49, 5.3 years and 65.54% respectively. All patients had infertility with 83.78% primary and 16.22% secondary infertility while menstrual dysfuction especially hypomenorrhoea (31.75%), oligomenorrhoea (32.48%) were seen in respective cases. Constitutional symptoms like pyrexia (21.62%), weight loss (31.75%) appetite loss (33.5%) and abdominal pain (11.48%) and pelvic pain (27.70%) or abdominal mass (8.78%) and pelvic masses (35.81%) were also seen. Diagnosis of FGTB was made on endometrial or peritoneal biopsy microscopy or culture for AFB or positive gene Xpert or positive polymerase chain reaction (PCR) or histopathological demonstration of epithelioid granuloma or on laparoscopic findings of FGTB. Various laparoscopic findings were tubercles on pelvic organs (45.27%), shaggy areas (white deposits) on pelvic organs (43.91%),beaded or convoluted tubes (9.45%), hyperemic tubes (29.05%), caseous nodules in pelvis (29.72%), encysted ascites (14.18%), abdominal adhesions (32.43%), pelvic adhesions (42.56%), calcified and rigid tubes (6.08%). The new laparoscopic sigmoid colonic adhesive band was seen in 49 (33.10%) patients of FGTB., Conclusion: The new laparoscopic "Sharma's Sigmoid colonic adhesive band" appears to be an important finding in patients with FGTB., (Copyright © 2019 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Background: Although gastrointestinal involvement is the most common site for extra-genital endometriosis, deep infiltrative endometriosis, which affects the mucosal layer, is very rare., Case Presentation: We present a case of a 41-year-old white woman with cyclic rectal bleeding. Magnetic resonance imaging was done, together with colonoscopy and histologic staining of biopsied samples, which led to the final diagnosis of intestinal invasive endometriosis with recto-sigmoid stricture. Our patient was treated symptomatically with stool softeners., Conclusion: This case provides a rare example of catamenial bleeding. It is important to keep invasive endometriosis on the differential diagnosis whenever a premenopausal woman has cyclical rectal bleeding.

Introduction: Rectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms., Material and Methods: We conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea., Results: Thirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group., Conclusions: Dolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

We report a case of sigmoid endometriosis diagnosed preoperatively based on endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) findings. A 42-year-old female came to us with left lower abdominal pain and bloating that had started 3 months prior. CT and MRI results showed wall thickening of the sigmoid colon. A colonoscopy procedure could not be completed because passage through the sigmoid colon was blocked due to severe stenosis, while mucosal biopsy samples obtained during that procedure could not confirm a diagnosis. EUS-FNA was then performed and specimens were obtained from the muscular layer with stenosis, which revealed a thickened hypoechoic lesion. Histological findings obtained by use of EUS-FNA demonstrated a large amount of fibrosis in endometrial glands and a diagnosis of sigmoid endometriosis was confirmed by additional immunostaining. Thus, a laparoscopic sigmoidectomy was performed, with sigmoid endometriosis finally diagnosed. Confirmation of a diagnosis of intestinal endometriosis based on histological findings of mucosal biopsy specimens obtained by colonoscopy is difficult, because endometrial implants are primarily located in the serosal and/or muscular layer. When safe aspiration is possible, we consider that EUS-FNA can be an effective method for preoperative diagnosis of intestinal endometriosis, which may contribute to avoidance of unnecessary or excessive surgery.

Pyogenic liver abscess (PLA) formation is a rare complication of Crohn's disease (CD). As symptoms often mimic a CD exacerbation, diagnosis can be delayed leading to severe disease. The current case report describes a case of a patient with a history of CD that was admitted with multiple PLAs, which persisted despite percutaneous drainage combined with antibiotics. After a sigmoid resection, the liver abscesses diminished rapidly., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Objective: To compare long-term surgical, clinical, and functional outcomes between conservative and radical surgery in patients with rectosigmoid endometriosis (RSE) and preoperative intermediate risk of segmental resection., Design: Retrospective cohort study (Canadian Task Force classification II-2)., Setting: Endometriosis tertiary level referral center, St. Orsola Academic Hospital, Bologna, Italy., Patients: Three hundred and ninety-two patients with RSE presented for complete macroscopic surgical excision between January 2004 and January 2017., Intervention: Assessment of laparoscopic bowel shaving, discoid excision, or segmental resection for the treatment of RSE., Measurements and Main Results: The 392 patients were divided into 3 groups according to surgical technique: shaving (n = 297; 75.8%), discoid excision (n = 33; 8.4%), and segmental resection (n = 62; 15.8%). Preoperative characteristics, surgical data, short- and long-term complications, and rates of proven and suspected recurrence were assessed. The segmental resection group had a higher rate of short-term complications compared with the discoid and shaving groups (17.7% vs 9.1% vs 5.4%, respectively; p = .004). The median follow-up time was 43 months (range, 12-163 months). Suspected and proven RSE recurrence rates showed no statistically significant differences among the 3 groups. There also were no significant differences concerning the rate of de novo chronic constipation and urinary retention., Conclusion: To date, there is no consensus regarding the choice between radical (segmental resection) or conservative (shaving, discoid excision) surgical management for RSE, particularly for patients with preoperative intermediate risk of bowel segmental resection (the gray zone). Our data suggest that conservative surgery is preferred over radical surgery in patients with RSE in the gray zone risk category, resulting in similar suspected and proven RSE recurrence rates and associated with fewer short-term complications., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To characterize clinicopathological characteristics of the non-neoplastic colorectal polyps for accurate diagnosis. Methods: 1 190 cases were collected from the Second Affiliated Hospital of Harbin Medical University from January 2012 to December 2016 and their clinicopathological characteristics were reviewed. Results: There were 746 males and 444 females patients with male/female ratio of 1.7∶1.0. The average age was 52 and 85.4% (1 016/1 190) of cases were over 40 years old. A total of 1 289 polyps were found in the study cohort including 1 238 inflammatory polyps (96.0%), 47 harmartomatous polyps (3.7%) and 4 other types of polypoid lesions (0.3%). Among 1 249 inflammatory polyps, 1 212 were inflammatory pseudopolyps (97.9%), 15 post-inflammatory polyps (1.2%), 8 inflammatory myoglandular polyps (0.6%), and 3 prolapse-type inflammatory polyps (colitis cystica profunda). Among 47 hamartomatous polyps, there were 39 juvenile polyps (83.0%), 8 Peutz-Jegher polyps (17.0%). Four polypoid lesions of endometriosis. Among 1 289 polyps, 751 polyps were located in sigmoid and rectum (58.3%). 168 polyps were pedunculated (12.9%) and 1 132 polyps were sessile (87.1%). Conclusions: For non-neoplastic colorectal polyps, the average age of patients is 40 years. The polyps generally involve the sigmoid colon and rectum. The most common pathological type is inflammatory pseudopolyp and the most common pathological type of hamartomatous polyp is juvenile subtype.

Introduction: Gastrointestinal elastofibromatous polyps are rare benign lesions. In 1985, Enjoji described elastofibromatous change of the stomach but since only isolated cases have been reported, with none in Spanish language journals. They present as single, usually asymptomatic, polypoid lesions, most frequently in the large intestine. Biopsy is essential for diagnosis and the main differential diagnosis is amyloidosis., Objective: To report the clinicopathological characteristics of a new series of gastrointestinal elastofibromatous polyps and review the pertinent literature., Patients and Methods: A retrospective study of cases of elastofibromatous polyps diagnosed between 2016 and 2017 in the Hospital Clínico de la Universidad Católica de Chile. Demographic data and histological slides stained with H&E, Verhoeff - van Gieson histochemical staining and Congo-red, were reviewed as well as previously reported cases., Results: 3 cases of gastrointestinal elastofibromatous polyps were found, all located in the large intestine. The location of 41 previously reported cases was: 34 (77%) in the large intestine; 6 (14%) in the stomach and 4 (9%) in the small intestine., Conclusions: Our findings concord with previously reported cases. As they are rare lesions, careful histopathological examination, complemented with histochemical studies, is necessary for a correct differential diagnosis, ruling out other possibilities, such as amyloidosis, with different clinical implications., (Copyright © 2018 Sociedad Española de Anatomía Patológica. Publicado por Elsevier España, S.L.U. All rights reserved.)

Epiploic appendagitis is as an acute painful condition of the fat on the outside of the intestine. Thus far, there have been no publications to our knowledge that appendagitis can be caused by mast cells or can be associated with chronic pain. A patient with multisystemic disorders suffered with both chronic and acute attacks of abdominal pain for a year. The worst attack led to surgical resection of an enlarged sigmoid colon epiploic appendage. Careful review of her complex medical history and mast cell stains of gastrointestinal biopsies led to the diagnosis of mast cell activation syndrome. Re-examination of the resected appendage using an immunohistochemical stain demonstrated a high mast cell density which is a new histopathological finding. Treatment of mast cell activation syndrome and other related syndromes led to marked improvement in her health, including all types of chronic abdominal pain., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Objective: To present a detailed description of a modified natural orifice specimen extraction (NOSE) colectomy technique. We also report the postoperative outcomes of our prospective case series when compared with conventional laparoscopic bowel resection in a relatively large series of patients., Design: Canadian Task Force classification II-1., Setting: A university tertiary referral center., Patients: The last 90 consecutive patients in our care with deep infiltrating endometriosis of the bowel are presented in this study. Patients were diagnosed at the 1st Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary., Interventions: We performed laparoscopic bowel resection using the transrectal NOSE technique and compared the results of the new operative method (n = 30) with traditional laparoscopic bowel resection (n = 60)., Measurements and Main Results: The median duration of surgery was 121 minutes in the control group and 96 minutes in the NOSE group (p = .005). According to the Clavien-Dindo classification, we observed a severe, grade IIIb or higher, overall complication rate of 3.3% among all 90 patients. In the control group, anastomosis insufficiency occurred in 3.3% of patients (2/60 cases), and in 1 patient with anastomotic leakage a rectovaginal fistula was observed (1.7%). There was no significant difference in the rates of severe postoperative complications (p = .55). The length of hospital stay in the control group was a median of 7 days (range, 5-13 days), whereas in the NOSE group it was 6 days (range, 3-11 days) (p < .001)., Conclusion: According to our findings, the use of NOSE colectomy offers a shorter recovery time and can eventually lead to a shorter surgery duration compared with traditional laparoscopic bowel resection., (Copyright © 2018 American Association of Gynecologic Laparoscopists. All rights reserved.)

Competing Interests: Competing interests: None declared.

Malakoplakia is a rare inflammatory disease, most commonly found in the urinary tract. It appears be related to a functional deficiency of macrophages, resulting in an inability to destroy digested bacteria and it is associated with various conditions that cause immunodeficiency. A rare case of malakoplakia of the colon in a healthy 68-year old male is presented. The patient underwent emergency surgery with colon resection and an end stoma with closure of the distal bowel (Hartmann's procedure), due to incarcerated ventral hernia and sigmoid-colon rupture. He underwent reversal of the Hartmann's procedure four months after the initial operation. The histological examination from the anastomotic rings revealed Michaelis-Gutmann bodies that are pathognomonic of malakoplakia. He received per os ciprofloxacin, bethanecol and ascorbic acid for 12 months. Follow-up endoscopy did not exhibit any signs of the disease. A case of a healthy patient presenting with malakoplakia without any underlying disease that causes immunodeficiency is extremely rare. Treatment of malakoplakia involves the eradication of microorganisms. Cholinergic agonists, such as bethanechol and ascorbic acid, as well as antimicrobial treatment with trimpethoprim/sulphamethoxazol and rifampicin are most commonly being used. Long-term antimicrobial treatment has been reported (6 months to 3 years).

Introduction: A brief resolved unexplained event (BRUE) describes an event associated with a change in muscle tone, color, respiration, and responsiveness that is unexplained after an appropriate examination. Some infants with higher risk BRUE may undergo endoscopy as part of their evaluation., Objective: This retrospective study aimed to identify the endoscopic findings in infants who have experienced a higher risk BRUE. We also compared the characteristics, prenatal, natal, and postnatal risk factors between 23 infants who underwent endoscopic evaluation and 23 race-matched/sex-matched/term-matched/preterm-matched infants who did not undergo endoscopic evaluation., Methods: This was a retrospective descriptive study. Infants were identified from a query of medical records using the ICD-10 code for BRUE (R68.13)., Results: Of 119 infants with BRUE, 23 infants with higher risk BRUE underwent an esophagogastroduodenoscopy and flexible sigmoidoscopy. Apnea (87%) was the most common presentation of BRUE. Most were female (57%) with a mean age at BRUE presentation of 2.73 months. We found 10 (43.5%) term infants and 13 (56.5%) preterm infants in our study. There were no significant differences in characteristics, prenatal, natal, and postnatal risk factors between the infants who underwent endoscopy and those who did not undergo endoscopy. The most common abnormal endoscopic finding was lymphonodular hyperplasia (LNH) associated with eosinophilia in the rectosigmoid colon. The proportion of females in the LNH group was significantly higher than the non-LNH group., Conclusion: Rectosigmoid LNH and eosinophilia, which are associated with milk soy protein intolerance (MSPI), were the most common findings on endoscopic evaluation. Although there is no proof of causation between MSPI and BRUE, MSPI should be considered in the differential diagnosis for higher risk BRUE.

Competing Interests: Competing interests: None declared.

Background: We have previously recognized segmental sigmoid polyps as an indicator of a fistula from Crohn's ileitis to the sigmoid or the proximal rectum. In the course of this study, we realized that many patients with this fistula had no sigmoid polyps, but the sigmoid was the site of marked inflammation and early or late stricture formation. Furthermore, in some patients with a stricture, the fistula was not recognized until the surgeon (or the pathologist) dissected an inflammatory peri-ileal and/or a perisigmoidal mass.In this study, we have sought to clarify the sequence of events by focusing on the segmental inflammation and the stricturing of the sigmoid so that its significance can be recognized as a local complication of the ileitis and the progression of its severity as opposed to arising sui generis., Materials and Methods: From our database of >3000 patients with inflammatory bowel disease at Lenox Hill Hospital, we identified 45 patients with Crohn's ileitis and ileosigmoid fistula (ISF): 24 had segmental sigmoid polyps and 18 had segmental inflammatory sigmoid strictures. The fistula was first seen by imaging in 36 patients, but not until resection by the surgeon or dissection by the pathologist in 7 patients., Results: The method of diagnosis for the initial recognition of the ISF and the sigmoid stricture is presented in Table 1. In 36 of the 45 cases, the ISF was recognized by radiologic imaging. In total, 31 of the 36 cases required surgical intervention, not because of the fistula, but because of small-bowel obstruction due to the ileitis. In 7 of the 31 (22%) cases, the fistula was recognized only by dissection of the inflammatory ileosigmoid mass by the surgeon or examination of the surgical specimen by the pathologist. The sequence of events from the originating ileitis to the ISF to the segmental sigmoid polyposis and stricture, with the resulting sigmoid obstruction, is shown in Figures 1A-E., Conclusions: We emphasize the natural history of the ISF so that its recognition will lead to earlier medical management of the originating ileitis. Furthermore, it adds evidence of the recognition that the causative agent of Crohn's disease is carried by the fecal stream.

Background: Neonatal sigmoid volvulus is a rare entity. It is associated with Hirschsprung's disease. Presentation is acute abdominal distention, vomiting and obstipation. Abdominal radiograph will show the "coffee bean" sign, but this is frequently missed and the diagnosis requires a high index of suspicion. Treatment options include contrast enema, colonoscopy or laparotomy, depending on the condition of the baby and local availability., Population and Results: During the last 6years, 6 infants with sigmoid volvulus were treated in our department. Four presented during the first 48h since birth, and 2 presented at the age of 2 and 7weeks of age. One child was operated and 5 had primary contrast enema with radiologic de-volvulus. Rectal biopsy was performed in all cases; three children had Hirschsprung's disease. Those with normal biopsies responded well to rectal washouts. Two patients had early one stage transanal pullthrough and one had 2 further occasions of sigmoid volvulus prior to definitive surgery. All three recovered with an uneventful course., Conclusions: Neonatal sigmoid volvulus requires a high level of suspicion. Contrast enema is efficient for primary de-volvulus. Rectal biopsy should be performed and if positive for Hirschsprung's disease, surgery should be performed sooner rather than later., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Primary colonic lymphoma is a very rare malignant disease of the gastrointestinal tract, accounting for 14% of all malignant diseases in this location. It is classified in the group of extranodal lymphomas; its long-term asymptomatic progression makes it different from common colorectal carcinomas making its diagnosis very difficult, more often accidental. Gallstone ileus is quite an uncommon complication of cholecystolithiasis diagnosed with difficulty. Up to 50% of cases are diagnosed during surgery. The obturated location depends on the size of the stone, location of the conjunction between the biliary and gastrointestinal tracts, and also on any preexisting stenosis due to another unknown pathology., Case Report: We present a case of an 86-year-old man treated for acute diverticulitis with typical clinical symptoms. Following further examination (colonoscopy, computed tomography) revealed a tumour-like infiltration in the sigmoid colon wall and a voluminous polyp was suspected according to the colonoscopy. Computed tomography described an obstruction by a biliary stone tumbling through the cholecystocolonic fistula. Subsequent biopsy supported the suspected malignant etiology. The patient underwent resection of the sigmoid colon sec. Hartmann; an infiltration was found in the subhepatic space, which corresponded to the described fistulisation between the biliary tract and the colon. A large 40 mm gallstone was found in the resected sigmoid colon over the stenosis and the bowel wall showed diffuse thickening with several polyps; final histopathological assessment confirmed malignant lymphoma of the plasmocytoma type. No serious complications occurred in the postoperative period; after healing, the patient was transferred to hematooncology care., Conclusion: The article describes the presence of two rare diseases - colonic lymphoma and gallstone ileus. Clearly, without the biliary stone obstruction in the preexisting tumorous stenosis in the sigmoid colon, the malignant hematooncology disease would not have been diagnosed., Key Words: primary colonic lymphoma - gallstone ileus - complication of the cholecystolithiasis - extranodal lymphoma - acute diverticulitis.

Objectives: To evaluate the interest of rectal and vaginal filling in vaginal and recto-sigmoid endometriosis with MR imaging. To compare the results between a senior and a junior radiologist review., Methods: Sixty-seven patients with clinically suspected deep infiltrating endometriosis were included in our MRI protocol consisting of repeated T2-weigthed sequences (axial and sagittal) before and after rectal and vaginal marking with ultrasonography gel. Vaginal and recto-sigmoid endometriosis lesions were analyzed before and after opacification. The inter-reader agreement between senior and junior scores was studied., Results: Concerning vaginal and muscularis and beyond colonic involvement, no significant difference (P=0.32) was observed and the inter-reader agreement was excellent (K=0.96 and 0.97 respectively). Concerning serosa colonic lesions, a significant difference was observed (P=0.01) and the inter-reader agreement was poor (K=0)., Conclusions: Rectal and vaginal filling in endometriosis staging with MRI is not necessary no matter the reader experiment., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Autoimmune enteropathy (AIE) is a rare disease that causes intractable diarrhea not responsive to a gluten free diet and must be distinguished from refractory sprue. It is associated with circulating autoantibodies against goblet cells and enterocytes. AIE mainly involves the small intestines, with very few cases reported in adults. Because of the paucity of cases, the epidemiology of the disease remains unclear, and treatment is based on the cases found in the literature. Of the 35 adult cases reported, only 4 involved the colon. Because of the low number of cases, there have been no clear recommendations on treatment modalities with most reports heavily emphasizing steroids as the mainstay of treatment. We present the case of adult female patient who developed postpartum AIE and colopathy with profuse diarrhea successfully treated with adalimumab and a review of the literature. To the best of our knowledge, this case is only the fourth case of a tumor necrosis factor alpha antagonist being used in the treatment of AIE and the first case of adalimumab being used.

Objective: To provide a mapping of bowel occult microscopic endometriosis implants from colorectal specimens removed from patients who had undergone colorectal resection for deep endometriosis infiltrating the rectum., Design: A series of consecutive patients with deep endometriosis infiltrating the rectum or/and sigmoid colon, between January 2013 and December 2013., Setting: University tertiary referral center., Patient(s): Twenty-six patients with deep endometriosis infiltrating the rectum or/and sigmoid colon., Intervention(s): Surgical management by colorectal resection., Main Outcome Measure(s): Twenty-six patients with prospective recording of data (age, clinical history, symptoms, preoperative assessment, and intraoperative findings) underwent colorectal resection for bowel endometriosis. Mapping of occult microscopic endometriosis implants from specimens was established by histologic examination of 1,051 microsection slides taken from transversal macrosections of 3-mm thickness (40 microsections per patient on average)., Result(s): The mean (SD) length of colorectal specimens was 110 (42) mm. Microimplants were found at varying distances up to 54 mm from macronodule limits. Multiple macroscopic nodules were identified in five patients (19.2%). In 18 specimens (69%) diffusion of endometriosis microimplants was longitudinal, whereas in 8 specimens (31%) diffusion was concentrated around the macroscopic nodule. Respectively, 31%, 19%, 8%, and 4% of patients presented with endometriosis microimplants at 2, 3, 4, and 5 cm from macroscopic nodules., Conclusion(s): The present data suggest that in patients presenting with deep colorectal endometriosis, microscopically complete excision of rectal endometriosis may be unachievable because of bowel occult microscopic endometriosis implants located far from macroscopic nodules., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Gastrointestinalstromal tumors are rare neoplasms and represent 0,1% to 3% of all gastrointestinal cancers. They are the most frequent mesenchymal neoplasms of the gastrointestinal tract with a malignant potential and unpredictable behavior. The synchronous association with other primary gastrointestinal carcinoma has been rarely reported in the literature with increasing number in the last ten years. The associated Gastrointestinalstromal tumor is usually discovered incidentally during surgery for carcinoma. The limited number of these cases cannot confirm the existence of a common factor in tumorigenesis of these different tumors and other studies are needed to clarify the possible association. We report the first case in the literature of synchronous primary Gastrointestinalstromal tumors developed in small bowel diverticulum and mucinous adenocarcinoma of the colon., Key Words: Synchronous, Gastrointestinalstromal tumors, Adenocarcinoma, Colon.

Objectives: Deep infiltrating endometriosis (DIE) raises a number of diagnostic and therapeutic problems. Magnetic resonance imaging (MRI), the reference technique in endometriosis, is questioned for posterior pelvic lesions, especially in rectosigmoid locations. In this study, we describe a new technique called three-dimensional rectosonography (3D-RSG), which combines standard transvaginal ultrasonography (TVUS), 3-dimensional (3D) ultrasonography and the use of water for rectal contrast. We also assess the correlation between 3D-RSG and MRI in the diagnosis of rectosigmoid endometriosis., Study Design: This study included 50 consecutive women with symptoms suggestive of DIE. After colorectal enema, they underwent a gynecological examination and a 3D TVUS during which 120ml of water was injected in the rectosigmoid to improve the performance of the examination. All patients also underwent an MRI and surgery was offered to the patient if there was discordance between the two procedures., Results: Fifty women underwent 3D-RSG between May and November 2012. All procedures were well tolerated by patients. Two examinations (4%) were stopped for technical reasons. Nineteen rectosigmoid nodules were diagnosed in 18 women (36%). Eighteen of these nodules were also identified on MRI, and one (2%) nodule seen on MRI was not diagnosed by 3D-RSG. In 31 examinations (62%), neither technique identified an intestinal lesion. There was a concordance rate of 96% between the two techniques. Using MRI as the reference technique, 3D-RSG had a sensitivity of 0.95, a specificity of 0.97, a positive predictive values of 0.95, and a negative predictive value of 0.97. There was a 30.3 positive likelihood ratio and a 0.05 negative likelihood ratio., Conclusions: 3D-RSG seems an interesting new method for diagnosis of rectosigmoid endometriosis and is both feasible and well tolerated. 3D-RSG is highly concordant with MRI in this indication, although further studies are needed to confirm these primary results., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Very few studies have evaluated the expression of homeobox A10 (HOXA10) and steroid (estrogen and progesterone) receptors exclusively in deep endometriosis. Conclusions drawn from studies evaluating peritoneal and ovarian endometriosis are usually generalized to explain the pathogenesis of the disease as a whole. We aimed to evaluate the expression of HOXA10, estrogen receptor α (ER-α), progesterone receptor (PR), and PR-B in rectosigmoid endometriosis (RE), a typical model of deep disease., Methods: We used RE samples from 18 consecutive patients to construct tissue microarray blocks. Nine patients each were operated during the proliferative and secretory phases of the menstrual cycle. We quantified the expressions of proteins by immunohistochemistry using the modified Allred score., Result: The HOXA10 was expressed in the stroma of nodules during the secretory phase in 5 of the 18 patients. Expression of ER-α (in 16 of 18 patients), PR (in 17 of 18 patients), and PR-B (17 of 18 patients) was moderate to strong in the glands and stroma of nodules during both phases. Expression of both PR (P = .023) and PR-B (P = .024) was significantly greater during the secretory phase., Conclusion: The HOXA10 is expressed in RE, where it likely imparts the de novo identity of endometriotic lesions. The ER-α, PR, and PR-B are strongly expressed in RE, which differs from previous studies investigating peritoneal and ovarian lesions. This suggests different routes of pathogenesis for each of the 3 types of endometriosis., (© The Author(s) 2014.)