Heading in the Right Dissection: Toward an Endoscopic Cancer Cure in a Patient with Long-Standing Ulcerative Colitis
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MULTICENTER SEMINARS: IBD (MUSE: IBD)
Heading in the Right Dissection: Toward an Endoscopic Cancer Cure in a Patient with Long‑Standing Ulcerative Colitis Sanchit Gupta1,4 · Hiroyuki Aihara1,4 · Hirsh D. Trivedi2,4 · Amitabh Srivastava3,4 · Jessica R. Allegretti1,4 · Matthew J. Hamilton1,4
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Case Presentation Clinical Background A 67-year-old gentleman with a history of hypertension, stroke, coronary artery disease complicated by myocardial infarction requiring a drug-eluting stent, atrial fibrillation requiring anticoagulation with warfarin, and long-standing ulcerative colitis (UC) was evaluated for a large rectal polyp with high-grade dysplasia. He was initially diagnosed with UC at age 37, with initial complaints of loose stools, abdominal pain, and hematochezia. He had been a smoker and had quit 10–15 years prior to diagnosis. Initial colonoscopy showed mild-moderate chronic active colitis in a continuous pattern from the rectum to the ascending colon. He was treated with prednisone that was tapered to a low dose, on which he remained for 15 years. Subsequently, he was treated with maintenance oral mesalamine, with additional mesalamine enemas during flares of colitis, which were infrequent during the subsequent years. His flares were characterized by increased mucoid discharge and rectal discomfort or urgency with only rare bleeding or loose stool. Other medications were tried but not taken for a significant period of time including 6-mercaptopurine and budesonide. He reported only one flare of symptoms since 2014 and had not taken any medications for the last 2 years due to personal preference and absence of * Matthew J. Hamilton [email protected] 1
Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, MA, USA
2
Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
3
Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA
4
Harvard Medical School, Boston, MA, USA
daily symptoms. He had not reported fevers, night sweats, or weight loss. He had never experienced extraintestinal manifestations. He had been counseled regarding the risks of untreated mucosal inflammation but preferred to remain off maintenance treatment.
Endoscopic Surveillance Although endoscopic surveillance had been recommended for assessment of UC disease activity and dysplasia over the past 10 years, the patient was noncompliant. Colonoscopy in 2009 showed “congestion and ulceration” in the rectum, sigmoid, and descending colon with moderate chronic active colitis on histology from random biopsies, but was negative for dysplasia. He subsequently had limited outpatient follow-up until 2015. At that time, the rectum and distal colon again showed friability and erythema with moderate chronic active colitis without dysplasia seen on histology. Surveillance colonoscopy in November 2018 was notable for inactive colitis on histology in the sigmoid colon and rectum; nev
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