This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. This is a 64-year-old woman who is undergoing a screening colonoscopy, and you can see that we're about to intubate the terminal ileum. She is completely asymptomatic, and the abnormality that is seen here in the terminal ileum, what is the correct diagnosis? This lesion, I always say, is the best reason, perhaps the only really good reason, to go into the terminal ileum in patients who are asymptomatic, undergoing screening or surveillance examinations. This is an ileal carcinoid. They're rare. I have found nine of them in more than 50,000 colonoscopies, so one every 5,000 to 6,000 examinations, but they are worth finding when you do find them because they have a high tendency to metastasize early. When diagnosed endoscopically, about half of them are already metastatic. I think the key features are that it's submucosa. To differentiate it from a lipoma, you would need to take the forceps and push on it to see if it had a cushion sign, but lipomas are rare in the terminal ileum, and so I think carcinoid is probably the more likely diagnosis. I think also, especially on the left, that sharp angle that it makes where it joins the normal mucosal surface is more typical of a carcinoid than a lipoma. It's not an adenocarcinoma because it's not mucosally based. It's not lymphoid hyperplasia because it's too big, and lymphoid hyperplasia is always multiple in nature, so when this lesion is seen, you want to biopsy it. Even though it's submucosal, the biopsies will typically be positive. You can use a bite-on-bite approach if necessary. Once the diagnosis is confirmed, you stage the patient and then send them for surgical evaluation slash resection if they are surgical candidates.

screening colonoscopy

64-year-old woman

ileal carcinoid

metastasize early

biopsying the lesion