Colon
Other nonneoplastic
Lifting agent granuloma


Topic Completed: 9 November 2020

Minor changes: 9 November 2020

Copyright: 2020, PathologyOutlines.com, Inc.

PubMed Search: Lifting agent granuloma

Yevgen Chornenkyy, M.D., M.Sc.
Maryam Kherad Pezhouh, M.D., M.Sc.
Page views in 2020 to date: 107
Cite this page: Chornenkyy Y, Pezhouh MK. Lifting agent granuloma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/colonliftagentgranuloma.html. Accessed November 23rd, 2020.
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
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 the submucosa

Fresh ORISE in a background of red blood cells

Fresh ORISE in a background of red blood cells

Several months after injection of lifting agent

Several months after injection of lifting agent

Foreign body reaction to lifting agent

Foreign body reaction to lifting agent

Lifting agent granuloma

Lifting agent granuloma

Lifting agent is negative for Congo red

Lifting agent is negative for Congo red

Positive stains
Negative stains
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)
Board review style question #1

Which stain is most helpful to differentiate between lifting agent granuloma and amyloidosis?

  1. Congo red because amyloid stains positive with Congo red
  2. Congo red because lifting agent stains positive with Congo red
  3. Congo red because lifting agent granulomas are birefringent as they have two different refractile indices
  4. Thioflavin T stain because lifting agent granulomas are nonpolarizable
Board review answer #1
A. Congo red because amyloid stains positive with Congo red

Comment Here

Reference: Lifting agent granuloma
Board review style question #2

Histologically, pulse granuloma can be differentiated from lifting agent granuloma as they

  1. Are round in shape (well circumscribed), contain ribbons of glassy material and calcifications and are more limited in size
  2. Demonstrate acellular mucin-like quality with basophilic, amorphous and bubbly extracellular material with prominent hemorrhage
  3. Demonstrate prominent intramucosal and perivascular distributions
  4. Do not contain entrapped calcifications but show irregular, infiltrative pattern (border)
Board review 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
Back to top
Image 01 Image 02