WhatsApp Chat Summary: July 18, 2025 → August 5, 2025

A severe muriatic acid ingestion, the differential diagnosis of a perianal lesion (NET vs. papilla), pediatric polypectomy strategies, and the management of asymptomatic ileal ulcers.

Welcome to our bi-weekly recap of the lively discussions in our WhatsApp group! This summary compiles the key threads, cases, and insights shared over the past two weeks, directly from the chat transcript. It's designed to keep everyone in the loop—whether you missed a few messages or want a quick refresher. Remember, this is based solely on the discussion in the group.

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Upper-GI

• Caustic Ingestion: A 62-year-old female with schizophrenia reportedly ingested approximately 500cc of muriatic acid, resulting in extensive damage to the esophagus, stomach, and second portion of the duodenum. The esophageal injuries were described as Zargar 3a with 3b changes near the GE junction, and the patient also developed chemical pneumonitis. Participants discussed the use of dexamethasone, which was administered for both GI and respiratory indications, with one member noting its potential role in preventing delayed strictures in injuries of Zargar grade 2b and above.

• Asymptomatic Gastric Crohn's: For a patient with colonic Crohn's and histological gastric antrum involvement but no upper GI symptoms, one member affirmed adding a PPI to biologic therapy. Another participant cited "2025 BSG" recommendations for mild-to-moderate upper GI disease, which included a trial of PPIs.

• Unidentified Severe Esophagitis: Images showed esophagitis along the entire length of the esophagus in a patient with no history of caustic ingestion or relevant drug use. Differential diagnoses offered included GERD (LA Grade D), pill-induced esophagitis, lichen planus, exfoliative esophagitis, Crohn's disease, and Eosinophilic Esophagitis. The location was noted as a key diagnostic clue, with distal lesions favoring reflux and mid-esophageal lesions favoring pill-induced injury.

• Submucosal Gastric Lesion: A soft, bleeding submucosal lesion was presented in a patient with significant anemia. The differential diagnosis included metastases, NET, lipoma, GIST, endometriosis, and malakoplakia. Management strategies were debated, including EUS, biopsy, or direct resection. One member expressed concern that biopsies could induce fibrosis and complicate a subsequent resection, and suggested considering a full-resection with an Ovesco device given the bleeding.

Colon/Small Bowel

• Asymptomatic Ileal Ulcers: A case was presented of two small ileal ulcers found on screening colonoscopy in an asymptomatic 52-year-old smoker. Histology showed acute inflammation, but stool tests were negative and the patient had only minimal NSAID history. One participant noted NSAIDs can trigger Crohn's disease but felt further investigation was not warranted in an asymptomatic patient. Suggested management included observation, NSAID avoidance, smoking cessation, and considering a repeat colonoscopy in one year or periodic calprotectin checks if the patient is particularly concerned.

• Large Rectal Ulcer: A 66-year-old female presented with proctorrhagia, anemia, and a large rectal ulcer; the rest of the colon and ileum were normal. The differential included Ulcerative Colitis (UC), stercoral ulcer, Tuberculosis (TB), and Solitary Rectal Ulcer Syndrome (SRUS). The tissue was described as soft distally and hard proximally, leading one member to strongly suspect SRUS. An update confirmed the patient has a rectal prolapse.

• Differentiating UC from Crohn's: A member asked how to distinguish UC with a cecal patch from Crohn's disease. Another participant noted that a "periappendiceal red sign" is often seen with distal colitis, typically responds to mesalazine, and is not usually associated with upper GI involvement, making UC more likely.

• Rectal Lesion near Dentate Line: A discussion centered on a small lesion near the anal verge, with a differential diagnosis of a Neuroendocrine Tumor (NET) versus a hypertrophic anal papilla. Features favoring NET included its round shape and vascular pattern, described by one member as a "tree on sunset appearance". Management approaches discussed included EUS, band ligation, and endoscopic mucosal resection (EMR). For EMR, it was suggested to inject a mix of saline and lidocaine to manage pain due to the proximity to the dentate line. One member advised using a gastroscope for its maneuverability in low rectal resections.

Therapeutic Endoscopy Techniques

• Pediatric Polypectomy: For a pedunculated polyp in the descending colon of a 4-year-old, members discussed techniques to mitigate bleeding. Suggestions included pre-emptive clipping of the base before hot snare resection or placing an endoloop first. One member preferred clamping the base over using adrenaline in children, citing the high vascularity of juvenile polyps and anesthetic concerns. A potential risk of using a hot snare near a pre-placed clip is current transmission to the bowel wall.

• Complex Sigmoid Polypectomy: A case was shared of a large, hemorrhagic, long-stalked sigmoid polyp removed via hot snare after endoloop placement. Histology revealed T1 adenocarcinoma (R0 resection) with hemorrhagic changes, which were thought to be caused by torsion of the long stalk.

• Bleeding Control for Low Rectal Lesions: One member shared tips for managing bleeding from low-lying rectal lesions, including direct "finger hemostasis" or applying hydroxymethylcellulose.

• Technique for Submucosal Lesion Removal: For small subepithelial lesions, one member noted that submucosal injection can sometimes obscure the lesion, making it harder to resect. Another suggested marking such lesions with forced coagulation before injection, a technique also used in the duodenum.

Group Administration & Resources

• The group discussed the "EndoCollab Guide to Bleeding Management Strategies" book. Members suggested that future editions include QR codes linking to videos, a suggestion the author welcomed.

• A new book on endoscopic resection is planned, with an invitation extended to group members to contribute.

• A resident seeking fellowship training in Europe received suggestions for short ESGE courses and longer, hands-on training opportunities in India.

One-Line Take-Aways