Colon
Other nonneoplastic
Lifting agent granuloma
Editorial Board Member: Catherine E. Hagen, M.D.
Deputy Editor-in-Chief: Raul S. Gonzalez, M.D.
Last author update: 9 November 2020
Last staff update: 18 October 2021
Copyright: 2020-2024, PathologyOutlines.com, Inc.
PubMed Search: Lifting agent granuloma
Table of Contents
Definition / general | Essential features | ICD coding | Sites | Pathophysiology | Diagnosis | Prognostic factors | Case reports | Gross description | Microscopic (histologic) description | Microscopic (histologic) images | Positive stains | Negative stains | Sample pathology report | Differential diagnosis | Additional references | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2 | Board review style question #3 | Board review style answer #3Cite this page: Chornenkyy Y, Pezhouh MK. Lifting agent granuloma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/colonliftagentgranuloma.html. Accessed November 27th, 2024.
Definition / general
- Submucosal granulomatous reactive process due to the use of lifting agents during colonoscopy
Essential features
- Reactive process in the submucosa arising from reaction to lifting agents injected during colonoscopy
- Appearance changes over time
- Often forms prominent, hard, hyalinized, homogenously eosinophilic amorphous ribbons and globules with foreign body giant cells
- Should be differentiated from mimickers such as amyloid and pulse granuloma
ICD coding
- ICD-10: M60.28 - foreign body granuloma of soft tissue, not elsewhere classified, other site
Sites
- Luminal gastrointestinal tract
Pathophysiology
- Lifting agents such as Eleview (Cosmo Technologies, 2015, also known as SIC-8000) and ORISE (Boston Scientific, 2018) are injected in the submucosa underneath a lesion to create a fluid cushion between muscularis mucosae and muscularis propria in order to visualize that lesion for endoscopic resection
- Immediately after injection, the material has an acellular mucin-like quality (basophilic, bubble-like, amorphous)
- Over time (~ 2 - 3 months) it becomes prominent, hard, hyalinized, homogenously eosinophilic, forming amorphous ribbons and globules with foreign body giant cells, scattered eosinophils and fibrosis
- Median time interval for an Eleview or ORISE lifting agent granuloma to form is 16 weeks between injection and resection; however, the material can be seen as long as 31 weeks post injection (Am J Surg Pathol 2020;44:793)
Diagnosis
- Histology
Prognostic factors
- Outcomes of lifting agent granulomas are unknown as long term case studies are unavailable
- Portion of the gel not resected during polypectomy likely remains in the submucosa
- Hyalinized ribbons represent degrading agent or tissue reaction to the foreign agent (Am J Surg Pathol 2020;44:793)
Case reports
- 54 year old man had a partial colonic resection for an endoscopically unresectable tubular adenoma of the right colon (Case of the Month #507)
- 55 year old woman with a 35 mm tubular adenoma with high grade dysplasia in the rectum (Am J Clin Pathol 2020;153:630)
- 64 year old man with biopsy proven 15 mm, moderately differentiated adenocarcinoma in the gastric cardia (Am J Clin Pathol 2020;153:630)
- 73 year old woman with a 20 mm mucinous adenocarcinoma in the sigmoid (Am J Clin Pathol 2020;153:630)
- 76 year old man with a 70 mm tubulovillous adenoma, without high grade dysplasia, located in the ascending colon (Am J Clin Pathol 2020;153:630)
Gross description
- Often forms a well circumscribed submucosal nodule
Microscopic (histologic) description
- Morphology of the lifting agents changes with time (Am J Surg Pathol 2020;44:793, Am J Clin Pathol 2020;153:630, Mod Pathol 2020;33:1581):
- Immediately after injection: lifting agents demonstrate acellular mucin-like quality with basophilic, amorphous and bubbly extracellular material
- 1 day after injection: infiltrating neutrophils and a more solid and less bubbly texture
- 2 - 3 months after injection: prominent hard, hyalinized, homogenously eosinophilic, amorphous ribbons and globules with foreign body giant cells, scattered eosinophils and fibrosis
- ORISE and Eleview are neither refractile nor polarizable (Am J Surg Pathol 2020;44:793)
Microscopic (histologic) images
Contributed by Maryam Kherad Pezhouh, M.D., M.Sc.
Fresh ORISE in the submucosa
Fresh ORISE in a background of red blood cells
Several months after injection of lifting agent
Foreign body reaction to lifting agent
Lifting agent granuloma
Lifting agent is negative for Congo red
Contributed by Catherine E. Hagen, M.D. (Case #507)
Lifting agent granuloma
Positive stains
- Mucicarmine is positive in fresh state and negative after ~3 months (Mod Pathol 2020;33:1581, Am J Surg Pathol 2020;44:793)
- Studies have reported variable (positive, faint, negative) staining for PAS and PASD (Mod Pathol 2020;33:1581, Am J Surg Pathol 2020;44:793, Am J Clin Pathol 2020;153:630)
Negative stains
- Generally the lifting agent material is negative for Congo red and Alcian blue and is not evident on trichrome stain (Am J Surg Pathol 2020;44:793, Am J Clin Pathol 2020;153:630)
Sample pathology report
- Colon, left, polyp, polypectomy:
- Tubulovillous adenoma (see comment)
- Comment: The submucosa adjacent to tubular adenoma contains prominent hyalinized, homogenously eosinophilic, amorphous ribbons and globules with foreign body giant cells, scattered eosinophils and fibrosis consistent with lifting agent granuloma. Congo red stain is negative for amyloid. (Am J Surg Pathol 2020;44:793)
Differential diagnosis
- Amyloid:
- Prominent intramucosal and perivascular distribution
- Positive for Congo red (negative in lifting agent granuloma or pulse granuloma)
- Pulse granuloma:
- Benign entity occurring within the gastrointestinal tract
- Foreign body reaction to legume material embedded in the bowel wall or peritoneum due to ulceration or perforation (Arch Pathol Lab Med 2001;125:822)
- Round in shape (well circumscribed), contains ribbons of glassy material and calcifications
- In contrast, lifting agent granulomas do not contain entrapped calcifications but show irregular, infiltrative pattern (border) that occurs secondary to forceful injection of gel into tissue (Mod Pathol 2020;33:1581)
Additional references
Board review style question #1
Which stain is most helpful to differentiate between lifting agent granuloma and amyloidosis?
- Congo red because amyloid stains positive with Congo red
- Congo red because lifting agent stains positive with Congo red
- Congo red because lifting agent granulomas are birefringent as they have two different refractile indices
- Thioflavin T stain because lifting agent granulomas are nonpolarizable
Board review style answer #1
A. Congo red because amyloid stains positive with Congo red
Comment Here
Reference: Lifting agent granuloma
Comment Here
Reference: Lifting agent granuloma
Board review style question #2
Histologically, pulse granuloma can be differentiated from lifting agent granuloma as they
- Are round in shape (well circumscribed), contain ribbons of glassy material and calcifications and are more limited in size
- Demonstrate acellular mucin-like quality with basophilic, amorphous and bubbly extracellular material with prominent hemorrhage
- Demonstrate prominent intramucosal and perivascular distributions
- Do not contain entrapped calcifications but show irregular, infiltrative pattern (border)
Board review style answer #2
A. Are round in shape (well circumscribed), contain ribbons of glassy material and calcifications and are more limited in size
Comment Here
Reference: Lifting agent granuloma
Comment Here
Reference: Lifting agent granuloma
Board review style question #3
Which of the following features is characteristic of submucosal lifting agents (Eleview or ORISE)?
- Association with ruptured diverticula
- Involvement of vascular walls
- Positive for Congo red stain
- Surrounding giant cell reaction
Board review style answer #3
D. Surrounding giant cell reaction. Submucosal lifting agents frequently show a surrounding giant cell reaction. Amyloid will stain positive for Congo red and frequently is seen within vessels walls. Pulse granulomas are frequently seen in association with ruptured diverticula.
Comment Here
Reference: Lifting agent granuloma
Comment Here
Reference: Lifting agent granuloma
