Introduction: Cecal bascule is a rare form of cecal volvulus, which is characterized by an anterior and superiorly displaced cecum in turn causing large bowel obstruction. It accounts for 0.01% of adult large bowel obstructions. Here we present a case of cecal bascule in a cirrhotic patient. Case Description/Methods: A 63-year-old female with history of alcoholic cirrhosis (MELD 20) and cesarean section presented to the emergency department with intermittent hematochezia and melena. At admission, she was hemodynamically stable with a hemoglobin of 5.7 g/dL. She underwent esophagogastroduodenoscopy (EGD) which demonstrated small esophageal varices without stigmata of a recent bleed, antral gastritis, and duodenitis. Due to a largely unrevealing EGD, she was scheduled to have a colonoscopy. However, the patient had difficulties tolerating the bowel prep due to increasing abdominal pain. An abdominal X-ray demonstrated a large gaseous lucency in the right mid abdomen below the level of the transverse colon which was concerning for cecal bascule. A computed tomography (CT) scan of the abdomen demonstrated a redundant cecum folding anteriorly with superior rotation into the upper right hemiabdomen without definite point of transition and diffuse small bowel dilation up to 4.3 cm. Findings were consistent with a cecal bascule. Patient underwent an exploratory laparotomy with right hemicolectomy. Patient had a prolonged, complicated post-operative course with multiorgan failure and finally died 30 days after the surgery (Figure). Discussion: Cecal bascule involves the upward folding of the cecum as opposed to an axial twisting of the colon as seen in more common types of cecal volvulus. For this phenomenon to occur, a patient will often have a mobile and redundant cecum that causes the volvulus. This may occur as a congenital anomaly secondary to a failed fusion in development between the ascending colon mesentery and the posterior parietal peritoneum. Additionally, this may be acquired from abdominal adhesions, pregnancy or even after a colonoscopy. Like other types of volvuli, treatment of cecal bascule requires surgical detorsion to prevent further complications. It is therefore important that cecal bascule be identified early for proper surgical planning and appropriate intervention. In our case, the poor outcome was due to the underlying decompensated cirrhosis.[1997] Figure 1. Abdominal X-ray demonstrating a large gaseous lucency in the right mid abdomen near the transverse colon CT of the abdomen demonstrating an anteriorly and superiorly rotated cecum into the upper right hemiabdomen.

Introduction: Cap polyposis is a rare condition of the rectum or sigmoid colon manifested by inflammatory polyps covered by a thick layer of fibrinopurulent mucus. This condition typically presents as mucoid diarrhea and rectal bleeding, and patients are often prescribed antibiotics (such as those for Helicobacter pylori), steroids, infliximab, or aminosalicylates. Surgical management is an option for unresponsive disease, but endoscopic management has been rarely reported. Case Description/Methods: A 16-year-old boy had a 10-year history of mucoid diarrhea and occasional rectal bleeding and incontinence. Previous endoscopy revealed pseudopolyps in the rectum that appeared inflammatory with granulation tissue. Initial laboratory evaluation revealed mild iron deficiency, anemia, and hypoalbuminemia. The patient was treated with limited polypectomy, topical steroids, and diphenoxylate-atropine, which did not resolve his symptoms. A full workup for inflammatory bowel disease with an upper endoscopy, colonoscopy, and magnetic resonance enterography showed indications of marked polyposis in the rectum that was suggestive of "cap polyposis". Tests for H. pylori were negative. There was no improvement with metronidazole or with treatments to reduce straining during bowel movements. Repeat sigmoidoscopy showed diffuse 1-4-cm multilobulated polypoid lesions in the rectum. Initially ESD was considered but deemed unsuitable due to poor lifting of the lesions. Thus, wide field endoscopic mucosal resection (WEMR) was performed, Approximately 40 band ligations with snare endoscopic submucosal resection were performed with near complete removal of all of the lesions. There was no post-procedure bleeding, pain, or other adverse effects. The resected tissue specimen had signs of high-grade dysplasia away from the resection margins. The patient's symptoms resolved, and a second-look procedure 3.5 months later revealed only a slightly nodular area with no signs of dysplasia or cap polyposis. Discussion: Patients with cap polyposis typically report mucoid stools and rectal bleeding, and evaluations reveal a characteristic pattern on colonoscopy and pathology. For cases of cap polyposis in which conservative medical management fails, wide-field endoscopic mucosal resection is a viable option.