Large adenoma located in the rectum. LST inhomogeneous Granular type – Paris IIa+Is.

At the index colonoscopy, a hot snare “biopsy” was performed at the lower edge of the adenoma. Histology showed tubulo-villous (mixed type) adenoma with low-grade dysplasia.

Patient was referred for EMR.

EMR (piecemeal) was performed. Due to the previous performed hot snare “biopsy”, severe fibrosis and non-lifting sign, was found in a small, 7×8 mm area. This area was not resectable and was treated with soft coagulation.

Learning message:

Benign adenomas, in this case a LST inhomogeneous Granular type – Paris IIa+Is, with no clear signs of malignancy, should not undergo any form of biopsy.

Standard biopsy forceps can induce fibrosis, if tissue is taken at a flat area or at the edge of the lesion.

In this case, a hot snare was used to get tissue for histology resulting in severe fibrosis. Due to this, the EMR procedure was in-complete.