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Mucosal tears on endoscopic insufflation
  1. K Hata1,
  2. T Watanabe1,
  3. T Kanazawa1,
  4. S Kazama1,
  5. D Shida1,
  6. H Nagawa1
  1. 1Department of Surgical Oncology, The University of Tokyo, Hongo, Bunkyo-ku, Tokyo 113- 8655, Japan
  1. Correspondence to:
    K Hata;
    HATAK-SUR{at}h.u-tokyo.ac.jp
  1. M Cruz-Correa2
  1. 2Department of Medicine, Johns Hopkins University School of Medicine, Meyerhoff Digestive Disease IBD Center, Baltimore, Maryland 21287, USA; macruzco{at}jhsph.edu

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We read the paper by Cruz-Correa et al (Gut 2002;51:600) with great interest. They reported that similar haemorrhagic lacerations in the colon had not been described in any other gastrointestinal disease. We would like to present a patient with ulcerative colitis (UC) and diversion colitis showing an identical endoscopic finding.

A 32 year old Japanese man suffering from UC for 11 years was referred to our hospital in 1997 for treatment of intractable UC. His past medical history and family history were unremarkable. He had received more than 20 g of oral steroid at the time of referral. Furthermore, his condition was not relieved with medical treatment, and he underwent subtotal colectomy with ileostomy and mucous fistula formation in January 1998. At that time, it was planned to perform pouch operation a few months later. After the first operation, he was free from frequent bowel movements and the condition of the rectal remnant was under control with topical steroids. He was satisfied with the state of the ileostomy and did not want to undergo pouch operation in spite of our recommendation. Instead, he received surveillance colonoscopy to detect dysplasia of the rectal remnant annually after the operation. On surveillance colonoscopy in 2001, the rectal remnant was torn and the muscularis mucosa was exposed on endoscopic insufflation (fig 1), as in the reported case. Endoscopically, the remaining mucosa showed mild proctitis with a decreased vascular pattern, mucous exudate, and oedema, but no ulcers. The post endoscopic course was uneventful without any treatment, partly because the rectal remnant was diverted from the faecal stream.

Diversion colitis occurs relatively frequently after stoma formation for a variety of disorders, including inflammatory bowel disease (IBD), malignancy, congenital disorders, and functional disorders.1 As both the clinical and endoscopic presentations are quite similar to those of IBD, it is very difficult to differentiate IBD from diverting colitis. However, Frisbie et al reported that colonoscopy revealed mucosal erythema or friability in 94% of patients who had undergone diverting colostomy for neuropathic large bowel.2 Furthermore, we have never experienced the mucosa being torn by endoscopic insufflation in patients with ulcerative colitis in routine surveillance colonoscopy. Taken together, these results suggest that the mucosal tear might be attributable to diversion colitis in addition to UC in our case.

As annual surveillance colonoscopy is mandatory for longstanding UC, it should be noted that the defunctioned colorectum must be surveyed with great care in such cases.

Figure 1

Endoscopic insufflation of the rectal remnant resulted in a mucosal tear in a patient with ulcerative colitis undergoing subtotal colectomy, ileostomy, and mucous fistula formation. The hole seen in the centre was a mucous fistula.

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Author’s reply

Thank you for your interest in our article reporting colonic mucosal tears on endoscopic insufflation in three patients with collagenous colitis (Gut 2002;51:600). We read with great interest your case report of a patient with ulcerative colitis (UC) with diverting colitis who presented an identical mucosal tear during colonoscopic insufflation. To our knowledge this is the first time such a mucosal finding has been described in diverting colitis. We may be dealing with some underlying mucosal pathology that decreases the compliance of the colonic mucosa and results in mucosal tears. It would be interesting to know what were the histological findings of the colonic mucosa in your patient.

Your report might elicit further reports from other cases, which may contribute towards elucidating the pathophysiological process underlying these endoscopic findings.

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