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negligible. Therefore, I almost always place the patient back on their antithrombotic
agent on post-procedure day 1, unless there is an extenuating circumstance, I have
never had a delayed bleed and am well over 200 cold EMRs currently. The impetus
for delayed bleeding is diathermy-induced ulcers, and with cold, we just don’t
have that.
After resection would you routinely place clips to close the polypectomy site?
Cold EMR does not require clips. I think that this is a tough pill for people to
swallow sometimes. You take a big polyp out from the right colon and then leave it
unclipped, which can be a little unnerving for people. I think in all of the cold EMRs
I have done, I have placed two clips total and they were for vessels that were persis-
tently bleeding. The bottom line is that the observational data available suggest that
clips are not needed with cold EMR [4, 5].
Now for hot EMR the clinical trial data obviously suggest otherwise. The most
robust data for this are from LPS, a study published in Gastro in 2019 where they
randomized polyps larger than 2cm to clips vs. no clips following hot EMR [1]. In
patients who had right-sided polyps proximal to the splenic exure, the bleeding
risk in the clip arm was reduced by about two-thirds from 9% to 3%. The caveat to
this is that not every defect can be closed completely. In the LPS trial, only about
two-thirds of defects were able to be closed with clips, either because they were too
big, or in a difcult location. So, current evidence tells us that if you take out a large
polyp in the right colon using hot EMR you should attempt to close the defect
with clips.
How long would you hold apixaban afterward?
My anecdotal evidence suggests that if the polyp was removed with cold EMR,
anticoagulation can be restarted on day one after polypectomy. Every once in a
while, I will wait a little bit longer if I have a gut feeling that a patient is at low risk
for a cardio-embolic event but higher risk for bleeding. I may wait an extra day, but
otherwise I will restart the next day.
Would any of the above three answers differ if the patient was on clopido-
grel instead of apixaban?
Not based on my experience. Remember, most people on antiplatelet therapy are
receiving it for prophylaxis of cardiovascular stent thrombosis or stroke prophy-
laxis. Major cardiovascular and cerebrovascular events are a larger threat to these
patients’ lives, and therefore, the importance of promptly restarting anticoagulation
far outweighs the risk of having a delayed bleed from cold EMR.So, I would abso-
lutely resume these medications on day one.
Do you hold anticoagulation or antiplatelet agents prior to an elective
screening colonoscopy?
I do, and the reason is that you never know what you are going to nd. Personally,
I don’t do a lot of screening colonoscopies, but because I do EMR and I am comfort-
able doing higher-risk endoscopic maneuvers on an index colonoscopy, I want the
patient to be prepared for possible EMR.For example, if I nd a 5-cm polyp on a
screening colonoscopy I would remove it right there rather than bringing the patient
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back. With that being said, there are data from the Annals of Internal Medicine that
looked at cold snare vs. hot snare in patients on antiplatelet therapy and cold snare
was signicantly safer. So, we can do cold snare polypectomy on anticoagulation/
antiplatelet agents, and I would not hesitate to do that if the need arose, but gener-
ally, we don’t nd many situations where a patient is too sick to hold anticoagula-
tion/antiplatelet therapy for an appropriate length of time but is still appropriate for
screening colonoscopy. Having said that, if I’m called in to assist on a case where I
encounter an 8mm sessile polyp in a patient on anticoagulation I would have no
hesitation to remove it with a cold snare.
EMR
Case 3 A 68-year-old man comes in for his rst screening colonoscopy with his
community gastroenterologist and is found to have a 3-cm at adenomatous appear-
ing polyp in the transverse colon.
If a gastroenterologist in the community nds a large at polyp on an index
colonoscopy, should he generally remove it then, or come out and discuss it
with the patient after the procedure and set it up for another day? Or, for that
matter, should he refer it to someone who specializes in EMR?
This entirely revolves around the skill set of the endoscopist. This is a recurring
theme and something that I am very passionate about. For me personally, as some-
one who is a high-volume EMR provider and comfortable with techniques that
minimize the risk prole of EMR, I would have no hesitation taking this out at the
time of the index procedure. That being said, there are some medical-legal things to
consider. For example, if you are very cursory with your consent process and you
have not specically talked about high-risk interventions, it is very justiable to
bring the patient back.
However, the thing that I can’t stress enough is that if someone nds a large
polyp on colonoscopy and they don’t do a lot of EMR, the last thing you want to do
is to start taking out the polyp and not nish the job. Doing an incomplete polypec-
tomy causes a lot of submucosal brosis, which makes any attempt at salvage resec-
tion markedly more challenging. So, if you start resecting and then determine the
polyp is in a difcult spot, or it’s bigger than you thought it was, or it starts bleeding
and you decide to just stop, and refer it out, or attempt it another day, realize that
you’re jeopardizing the success of the polyp resection. A good way to increase the
chance of a patient needing surgery for a benign polyp is to do an incomplete EMR
before referring the patient to an expert center. So, if you look at the polyp and you
can’t tell yourself with 100% certainty that you can remove it, then you should not
attempt it. So, for your standard community practice general GI doc who sees a
gambit of GI pathology and is not a high-volume EMR person I would not resect
this for the reasons I have mentioned above.
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Do you feel like there is any role for EMR in an ambulatory endoscopy cen-
ter not attached to a hospital?
The reason not to do an EMR in an ASC, everything else being equal, is lack of
resources in case something goes wrong. If I run into trouble at an ASC, an emer-
gency surgery consultation is just not available. Part of the reason that the rate of
surgery for benign polyps continues to rise (at least through 2014 according to
observational data) is that a lot of people are averse to using EMR technique, but if
people can get more comfortable with cold EMR technique, understand the tech-
nique, understand that it is adequate, and fully grasp that the risk prole is markedly
reduced, I think many more of these polyps will be removed by gastroenterologists,
rather than being referred to surgeons. I think that doing a cold EMR at an ASC
becomes much more justiable because the likelihood of a complication, where you
need an emergency surgery consultation, is so negligible. Having an immediate
perforation from a cold EMR is a reportable case event, and the ones that have been
reported are near surgical anastomoses or in patients who have some sort of predis-
position. In a patient who has a native colon, no inammatory bowel disease, or
other risk factors, the chance of a perforation on a cold EMR is basically zero. So, I
think that it is completely justiable to use cold EMR techniques at an ASC.
What do you like to use to inject to lift polyps? Will you ever use saline for
lifting?
Typically, I do still lift polyps and will use one of the commercially available
viscous solutions. However, emerging observational data from Michael Bourke’s
group and others suggest that lifting for large cold resections may not be necessary
[5, 6]. However, I think the verdict is still out on that. LPS-2, which we are involved
in, is a 2×2 randomized trial comparing hot and cold EMR as well as commercially
available viscous injectate vs. saline and methylene blue. So, there should be some
comparative data on solutions from this trial. A lot of the data on injection solutions
have looked at durability of lift, completeness of resection, resection time, and
polyp recurrence, so establishing meaningful endpoints is important. Sometimes
these solutions can be cost-prohibitive for smaller centers. In those circumstances,
saline or hydroxyethyl starch and methylene blue is an appropriate alternative. For
me personally, with EMR, unless I am doing an underwater EMR technique, I am
still injecting a submucosal agent.
This is your partner’s case and he is doing a submucosal injection and is nding
that this relatively at polyp is attening out further with the injection making it
difcult to get a snare around the polyp and calls you in for advice.
How do you avoid this problem with your injection?
One benet of the commercially available injectates is that for the most part they
don’t tend to spread laterally as much as saline does. With that said, atness of
injection can happen for a couple of reasons. First, it can be a technique problem
and there are ways to potentially combat this. They include:
Inject Slowly. If the injectate seems to be spreading laterally and not lifting, stop
and consider re-inserting the needle in a different place.
Direct the tip of the colonoscope upward to create tension away from the colon
wall while injecting.
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If using saline and not using a viscous solution (commercial or otherwise), con-
sider changing.
Second, there are other situations, like ulcerative colitis, where you might get
lateral spread of the injectate. Even if these patients have quiescent colitis, they have
had some submucosal brosis over time and this interferes with lifting.
There are some endoscopic techniques to try to get the snare to capture, even
when the polyp remains at and doesn’t lift. Some of those are more advanced tech-
niques that I do not recommend unless one is trained. One example is to do a muco-
sal incision as if you were doing an endoscopic submucosal dissection around the
polyp and then create a little notch around the mucosa where the snare is able to
latch on and grab the tissue. This is commonly referred to as precut EMR.
Sometimes, just changing your snare to a thinner wire snare is enough to combat
this problem. Sometimes approaching the polyp from a different angle will help.
Is there anything to do once attening has occurred?
Mucosal incision is one suggestion. Another suggestion is to convert to an under-
water technique. Here, you take air out of the colon and then you immerse the colon
with water using your pedal. Water immersion has a buoyant effect on the submu-
cosa. This was rst described by Ken Binmoeller in San Francisco when he was
doing endoscopic ultrasound. He noticed that when water was instilled while look-
ing at submucosal lesions, there was expansion of the submucosa and he parlayed
that into the world of endoscopic resection. Underwater EMR gives you a lot of
benets, it allows you to work in a collapsed space, and tissue is much easier to grab
in a collapsed space. It allows you to work very close to a polyp, giving you a mag-
nied view of everything. So, in this situation I would probably quickly convert to
an underwater technique.
Do you always inject into the polyp? Do you ever inject just adjacent to it?
It depends on the size and location of the polyp. I will inject into the polyp if it is
2cm. or less, especially with sessile serrated polyps, just to get one uniform injec-
tion. If it’s a big polyp or in a saddle distribution (meaning over a fold), I will typi-
cally start by injecting on the oral side of the polyp and then work toward the anal
side. I won’t try to inject a whole 5cm polyp at once, I will inject the part that I am
going to cut out rst and then I will re-inject and take the rest of the polyp. This
seems to keep things plump when you are doing the cutting and doesn’t allow injec-
tate to diffuse out while you are working on the other side of the polyp.
What is your technique for removing large polyps using a cold snare
technique?
The most important things are the same regardless of cold vs. hot technique. You
want the scope to be straight, reduced, and have the polyp at the 5:00 to 7:00 region.
I always lock my wheels. I want scope stability as much as possible.
The main difference is that cold snares are smaller and so typically you are tak-
ing less tissue out per bite. When I am teaching people, I compare it to mowing your
lawn. You start on the edge near your sidewalk and you are then going to have some
overlap every time you go back and forth. So, you put your snare down, you make
a cut, it doesn’t matter how big your rst cut is, and then your second cut is going to
lay on the edge of the resection defect of your rst cut and is going to grab mucosa.
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So, if you are working left to right, the left side of the snare is going to sit in the
submucosa where you made your rst cut, the right is going to scoop tissue on the
right, you are going to bring it together, and move down the line. When the back side
is done from left to right you move a little toward the anal side and overlap a little
with the resected zone on the oral side and repeat the process until you are done.
When you remove bigger polyps, you are going to see some lumps and bumps of
adenoma that don’t come up with the cold snare and you can go back and take those
with snare or avulsion techniques. For the most part, it is a systematic process and
it goes a lot faster than people think it will.
When you’re removing a large at polyp in the cecum would you manage it
differently to avoid complications?
Probably not. While cecal polyps can hide in funny places, like behind the ileo-
cecal valve or juxtaposed to the appendiceal orice, making things more challeng-
ing, for the most part my technique is going to remain the same whether the polyp
is located in the cecum, ascending colon, or transverse colon.
What are the polyps that you will send to the surgeon?
Usually, surgeons send me polyps. It is common for patients to be referred to
surgery for “unresectable” polyps by general community gastroenterologists. We
now know that surgery is associated with higher morbidity and mortality, higher
rates of procedure intervention, higher cost, and longer hospital stays than endo-
scopic resection. For the vast majority of people, surgery is not the best option.
Some gastroenterologists don’t understand the full implications of surgical inter-
vention required to address the lesions detected. Take for example a case where two
large “unresectable” polyps are detected in the ascending colon and splenic exure.
What they need to think about is that the surgery that is required to address this
would require a subtotal colectomy and that has a major impact on the patient’s
quality of life. There are data from Stanford and Australia that both suggest that in
patients who are referred to surgery for large, “unresectable” polyps, referral to an
expert endoscopist or a high-volume EMR center can avoid surgery 90% of the time.
Having said that, there are a few instances where I will send the patient to a sur-
geon. The rst is recalcitrant polyps. What I mean by this is if we remove a large
polyp and bring the patient back 6months later to take another look there is a sig-
nicant recurrence of polyp. We then resect the polyp regrowth. Then, on follow-up,
6-12months later there’s signicant recurrence and you realize that you are not able
to completely resect it. These situations are more common in patients who have
signicant brosis, either because they had a previous, limited EMR attempt prior
to seeing me, or they have some other condition that predisposes them to submuco-
sal brosis like ulcerative colitis.
The second instance is when I am referred to a polyp that is presumed to be
benign but it turns out there is invasive cancer on the resection specimen.
Occasionally, this is apparent on initial inspection using careful optical observation
with electronic chromoendoscopy, near-focus imaging, and you see clear evidence
of deep submucosal invasion. You do targeted biopsies, it proves cancer. Those
patients go to surgery, or, the polyp may look benign, but once you start taking it
out, it becomes obvious that there is cancer by the way it is behaving. Either it’s not
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lifting well, there is a lot of tissue that is matted to the submucosa, or it is bleeding
more than you would expect. All of those are indicators that there is invasive cancer.
In those circumstances, they go to surgery as well.
Most of the time, if I am referred to a polyp that has not been intervened on, I am
successful in removing the polyp and keeping the patient out of the operating room.
It is usually these few extenuating circumstances that could lead to an operation.
The vast majority of time, if someone else doesn’t partially remove the polyp we are
usually able to durably resect and cure those lesions.
What are the endoscopic features that most strongly suggest deep submuco-
sal invasion?
I would encourage people to become familiar with a pit pattern classication
such as Kudo. I think the simplest one for me is the NICE classication. It is a
narrow-band classication validated on the Olympus platform. It is a way to distin-
guish hyperplastic and serrated lesions from traditional adenomas and from submu-
cosal invasive cancer. It is a very simple classication, and I think you just have to
look very carefully. If you are using a 190-series adult scope, do near-focus imag-
ing. Sometimes, imaging something underwater is another way to get a nice per-
spective of the pit pattern.
I do very careful optical examination before I remove a polyp, because if there is
submucosal cancer my approach is very different. Another important nding on the
optical examination is surface ulceration. The nding of surface ulceration, visible
on regular high-denition white light imaging, goes hand in hand with NICE type
III pit pattern classication. If something looks ulcerated on the surface, the chance
of submucosal cancer is high regardless of the size.
I just had a case where a patient was referred by a community gastroenterologist
for EMR of an 11mm polyp in the cecum with high-grade dysplasia. Although the
polyp was not that large it had surface ulceration and I explained that I was con-
cerned about possible invasive cancer, based solely on the surface ulceration. I did
the EMR.The polyp lifted great, we did an en bloc resection, the base of the polyp
looked pretty reasonable, clipped it, and the pathology came back as margin- positive
invasive adenocarcinoma. He ended up with a hemicolectomy anyway.
Another indicator of malignancy is any lesion that is near circumferential. The
chance is high that there is an invasive cancer somewhere in that lesion. Then, if
something is just bleeding or oozing more than it should, that is usually a good
indication that you might be dealing with cancer.
What about the use of the Paris classication to suggest the likelihood of
deep submucosal invasion?
In the Paris classication, lesions that have a central depression, either IIc or II
a+c lesions (something that is raised on the edge and depressed in the middle),
can harbor cancer. These are usually accompanied by surface ulceration. Lesions
that have a 1-s component (which is what we call a dominant nodule) tend to har-
bor high-grade dysplasia, not necessarily cancer per se. I always look for those
areas specically to ensure that I’m concentrating on getting those sections out.
So, as far as the benign Paris lesions, those are the two that would indicate poten-
tial cancer.
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Pedunculated Polyp
Case 4 A 55-year-old man is found to have to have a large (about 1.8cm) pedun-
culated polyp on a thick stalk.
Is there any role for cold snare polypectomy of a pedunculated polyp?
I would say no, it’s just going to turn into a bloody mess if you are able to tran-
sect it. If you are unable to transect it, which is the most likely scenario because you
are cutting through a huge stalk and big vessel, then you are just getting yourself in
trouble. These polyps invariably require hot snare.
I will take out pedunculated polyps less than 1cm in size in the left colon with
cold snare, especially if I already have a cold snare out and have already been using
it. They will bleed a little bit more in the short turn, but they will thrombose and stop
quickly.
Do you like to pre-treat the stalk in patients with a thick stalk? If so, what
do you like to use?
I will if it is a big polyp and I am having difculty getting a snare around it. If
you inject standard epinephrine into the stalk of the polyp that will diminish the ow
from the feeding vessel(s) and result in an ischemia-induced reduction in size. The
polyp will shrink in real time and that may make enough of a difference to change
something from not capturable to capturable. Stalk, injecting into the stalk.
If I can get a snare around a polyp comfortably, I’m usually not pre-treating the
stalk. When I’m removing a polyp on a thick stalk, I know beforehand that I will
probably clip the stalk afterward. I prefer to clip it following polypectomy, rather
than before, because if a stalk starts bleeding post-polypectomy and you clip it and
it stops, then you know your clip is in the right place and you can feel good about it.
Some people will place standard endoscopic clips at the stalk base prior to pol-
ypectomy. I have avoided doing that because the stalks are frequently thicker than
the standard 11mm clips and you can’t be sure that you are effectively tamponading
the vessel. Now that there are larger, 18mm clips, and there may be more of a role
for them, but so far that is not my practice.
If I encounter a very high-risk polyp with a thick stalk and I am tempted to clip
prior to polypectomy, I prefer to use a detachable snare. A lot of people are uncom-
fortable with the deployment of a detachable snare because the deployment systems
can be a little tricky. When you cinch down on a detachable snare, you run the risk
of cold-ligating the stalk causing heavy bleeding if you aren’t careful or you deploy
it and it isn’t tight enough, which makes it ineffective. So, there is a very systematic
way to open the snare, get it around the polyp, and get the cinch down to the point
where you know that there is tamponade of the vessel that is indicated by color
change of the polyp as you tighten the loop.
In those cases, where you opt to use hot snare discuss the various cautery
settings that are available and how you decide on the particular ones in a par-
ticular setting.
There has always been a blue-pedal-yellow-pedal debate (on the ERBE). I have
always been on team yellow, but there was a pretty well-done randomized control
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trial looking at this exact question, yellow vs. blue pedal for complex polypectomy,
and found no difference in resection success and complications [7], so it looks like
you can probably do either in those circumstances. Some people feel that the blue
pedal has more cautery associated with it so maybe your bleeding risk is going to be
less. Any source of blended current (if you are using an ERBE or similar device) is
going to have some cautery current built-in with the cutting current. There is usually
some tissue impedance that directly feeds back to the generator that allows it to alter
the settings as it cuts through. So, I still use the yellow pedal for pretty much every-
thing (ENDOCUT Q for ERBE systems). Then it’s just personal preference on cut
duration, cut interval, and effect. I think whatever you are comfortable with is what
you should stick with.
Your partner is performing the polypectomy and has not pre-treated the stalk.
There is heavy bleeding at the stalk immediately following polypectomy.
How do you like to manage this?
You can do a handful of things. I think mechanical tamponade is the best
approach. If you want to inject epinephrine to slow things down so you can better
see where the bleeding is coming from that is also completely appropriate. But
standard endoscopic clips are ne in this scenario, and I think that while heavy
bleeding does impair visualization, I always tell the fellows that bleeding is a good
thing because once it is treated and the bleeding stops you know that your clips are
in a good position.
Post-Polypectomy Bleeding
Case 5 Your partner performs a cold snare polypectomy on a 48-year-old patient
in good health. The polyp was described as 6mm in size, located in the sigmoid
colon. That Friday night you get a call from the patient that he has had two bloody
bowel movements since the colonoscopy that morning, about 4h apart.
How would you advise this patient?
Anytime the patient calls, regardless of how the polyp was taken out, you want
to clearly assess their symptoms. Are they lightheaded? If so, is this postural?
If a polyp was taken out in the left colon, it was under 1cm in size, and removed
cold, the chance of having a bleed that requires intervention is well below 1%. What
I mean by that is not the proportion who have cold snare polypectomy, but the pro-
portion of those who call you with bleeding after a cold snare of a diminutive polyp
in the left colon. So, reassurance is the most common thing, but besides that, I want
to make sure we are keeping an eye on things, the patient knows when to go to the
emergency department, etc.
The next morning the patient is still having bloody bowel movements and
you decide to perform a repeat colonoscopy that weekend. There is ongoing
bleeding from the polypectomy site. How would you treat it?
I would clip it.
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There is frequently mild oozing of blood at the time of cold snare polypec-
tomy. How do you decide whether the bleeding will stop spontaneously? When
does the bleeding appear excessive?
It is very unusual for something to bleed persistently at the completion of a pro-
cedure. Most things have slowed down to a trickle or have stopped completely, even
after a big EMR.Every once in a while, you can hit a big vessel with a cold snare so
if something doesn’t look like it is slowing down and you have given it 5min or so,
nobody is going to fault you for putting a clip or two on there, but this is rarely
needed with cold polypectomy.
Do you ever see delayed bleeds after a cold snare polypectomy starting up
days after the event?
It is very uncommon. Again, we think the impetus for delayed bleeding is dia-
thermy and ulcer formation so it just rarely happens.
Slightly different scenario is the polyp is now 1.5cm in size and was located in
the descending colon and removed with hot snare. The bleeding starts up 7days
post-procedure and is quite brisk. You admit the patient and perform a colonoscopy
the next morning. There is active bleeding from the polypectomy site.
What will you use to stop the bleeding in this case following hot snare
polypectomy?
I think clips are still my choice. Usually, with clips you can focus your treatment.
You will likely see a big ulcer and it’s going to look ugly, but the culprit vessel is
going to be very obvious and so typically one or two clips on the culprit vessel are
going to be enough for hemostasis to occur. I wouldn’t see a need to close the entire
defect 7days later, just treat the bleeding site because it’s unlikely that anything else
in that ulcer is going to bleed at that point.
References
1. Pohl H, Grimm IS, Moyer MT, etal. Clip closure prevents bleeding after endoscopic resection
of large colon polyps in a randomized trial. Gastroenterology. 2019;157:977–984.e3.
2. Klein A, Tate DJ, Jayasekeran V, etal. Thermal ablation of mucosal defect margins reduces
adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterology.
2019;156:604–613.e3.
3. Mehta D, Loutfy AH, Kushnir VM, etal. Cold versus hot endoscopic mucosal resection for
large sessile colon polyps: a cost-effectiveness analysis. Endoscopy. 2022;54:367–75.
4. Mangira D, Cameron K, Simons K, etal. Cold snare piecemeal EMR of large sessile colonic
polyps >/=20mm (with video). Gastrointest Endosc. 2020;91:1343–52.
5. van Hattem WA, Shahidi N, Vosko S, etal. Piecemeal cold snare polypectomy versus conven-
tional endoscopic mucosal resection for large sessile serrated lesions: a retrospective compari-
son across two successive periods. Gut. 2021;70:1691–7.
6. Tate DJ, Awadie H, Bahin FF, etal. Wide-eld piecemeal cold snare polypectomy of large
sessile serrated polyps without a submucosal injection is safe. Endoscopy. 2018;50:248–52.
7. Pohl H, Grimm IS, Moyer MT, etal. Effects of blended (yellow) vs. forced coagulation (blue)
currents on adverse events, complete resection, or polyp recurrence after polypectomy in a
large randomized trial. Gastroenterology. 2020;159:119–128.e2.
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Switzerland AG 2023
W. H. Sobin et al. (eds.), Managing Complex Cases in Gastroenterology,
https://doi.org/10.1007/978-3-031-48949-5_18
Chapter 18
Rectal Incontinence
LingMei andKrupaPatel
Case 1 A 73-year-old woman comes to your ofce complaining of rectal inconti-
nence that has occurred on ve occasions. With each episode, she is aware of the
urge to defecate but can’t “hold it” long enough to get to the toilet. There were a
number of other episodes when she felt the urge to defecate, but was just barely able
to get to the toilet on time. This all started about 3months previously, after a bout
of “food poisoning.”
Is this passive, urge, or seepage incontinence? What is the distinction
between the three forms, and why is it important?
This is urge incontinence. Urge incontinence is the discharge of rectal contents
despite active attempts to retain them. Passive incontinence is the involuntary dis-
charge of feces or atus without awareness. Fecal seepage is involuntary seepage
with otherwise normal evacuation.
The patient has a history of a complicated pregnancy when she was 20years old,
which required an episiotomy. She has had no other anorectal operations and no
abdominal surgery. Her bowel movements occur once or twice a day, which is
unchanged from her norm. She denies urinary incontinence. Her last screening
colonoscopy was 4years ago, when she was 69, which was normal, and no biopsies
were taken. Her physical examination is unremarkable except for the rectal exami-
nation, where she has a slightly diminished rectal tone.
L. Mei (*)
Department of Medicine, GI/Hepatology Division, Medical College of Wisconsin,
Milwaukee, WI, USA
e-mail: lmei@mcw.edu
K. Patel
Methodist Medical Group, Dallas, Texas, USA
e-mail: KrupaRpatel@mhd.com
https://t.me/medicina_free
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