DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Family history of colorectal cancer.
2. Abdominal pain and bloating.
3. Weight loss.
POSTOPERATIVE DIAGNOSES:
1. Two colon polyps including a large polyp of the transverse colon.
2. Mild sigmoid diverticulosis with tortuosity.
3. Small internal hemorrhoids.
4. Moderate to severe atrophic-appearing gastritis.
PROCEDURE PERFORMED:
1. Colonoscopy with hot snare polypectomy, biopsy and injection of India ink for tattooing.
2. Esophagogastroduodenoscopy with gastric and small bowel biopsies.
ENDOSCOPIST: John Doe, MD
MEDICATIONS: MAC anesthesia.
DESCRIPTION OF PROCEDURE: Informed consent was obtained after explanation of the risks, benefits and alternatives to the procedures. Specific risks discussed with the patient included, but were not limited to, the risk of bleeding, infection, perforation, missed polyps and sedation. The patient was premedicated in order to obtain conscious sedation. Rectal examination was normal.
Next, a video colonoscope was inserted into the rectum and gently advanced to the rectosigmoid junction where there were acute angulations encountered and mild to moderate difficulty passing the area. With gentle maneuvering, we were able to advance the scope past the distal sigmoid colon. At this point, the scope could easily be advanced to the cecum, which was normal and identified by the appendiceal orifice and ileocecal valve. The valve was intubated and the distal 5 cm of terminal ileum appeared normal. Scope was withdrawn back into the cecum, which was normal as was the ascending colon and the hepatic flexure. There was a diminutive 4 mm polyp; it was biopsied and removed and sent to pathology.
Also of note, in the ascending colon was a 2 cm yellowish-appearing submucosal lesion most consistent with lipoma. This was biopsied and sent to pathology. In the mid transverse colon, there was a 1 cm sessile polyp that was removed using hot snare polypectomy technique. There was excellent hemostasis. The polyp was retrieved and sent to pathology.
Next, the polypectomy site was injected with India ink for tattooing. The splenic flexure, descending colon and proximal sigmoid colon were normal. In the distal sigmoid colon, there was severe tortuosity, spasm and mild narrowing. A couple of diverticula were seen consistent with mild to moderate diverticular disease. Some of the narrowing may also be due to external adhesions related to a prior hysterectomy. Within the rectum, small internal hemorrhoids were seen on frontal and retroflexion views. Greater than 10 minutes were spent examining the mucosa between the cecum and the rectum. The patient tolerated the procedure well.
Next, a video endoscope was inserted into the esophagus under direct visualization without difficulty. It was advanced down to third portion of the duodenum, which appeared normal. Small bowel biopsies were obtained in order to rule out celiac disease and second portion of duodenum was also normal as was the duodenal bulb. The entire stomach had moderate severe erythema seen throughout, both on frontal and retroflexion views consistent with moderate diffuse gastritis. The gastric body and fundus had a paucity of folds consistent with atrophic gastritis.
Multiple random biopsies were obtained throughout the stomach in ordered to rule out a Helicobacter pylori infection to better characterize the gastritis. Retroflexion view did not show any additional abnormalities. The esophagus was normal. The GE junction and Z-line were both seen at 39 cm incisors. The Z-line was sharp. The patient tolerated the procedures well and was returned to the recovery unit in stable condition.
IMPRESSION:
1. Colon polyps status post removal.
2. Narrowed rectosigmoid colon, likely due to adhesions versus diverticular disease, which may be a contributing factor to intermittent abdominal bloating versus irritable bowel syndrome.
3. Moderate to severe atrophic gastritis.
PLAN:
1. Check results of colon polyp pathology. If there are no ominous changes, would repeat colonoscopy in 3 years once again using MAC anesthesia and would also consider using a pediatric colonoscope.
2. Check results of biopsies from submucosal lesion, rule out lipoma.
3. Check results of gastric and small bowel biopsies.
4. Continue Levsin 4 times daily as needed.
5. Add omeprazole 40 mg daily for at least 8 weeks.
6. Call office for biopsy results in 1 week and follow up in the office in 3 to 4 weeks.
