DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Age-based risk for development of colon cancer.
POSTOPERATIVE DIAGNOSIS: Sigmoid diverticulosis.
PROCEDURE PERFORMED: Colonoscopy with biopsy.
ANESTHESIA: Fentanyl 100 mcg, Versed 5 mg.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was taken to the endoscopy suite and placed in the left lateral decubitus position. After adequate intravenous sedation, digital rectal exam was performed, which was normal. A colonoscope was inserted into the rectum and easily negotiated to the cecum. The ileocecal valve and appendiceal orifice were identified and photographed. The cecum took a fairly sharp angulation, and on the lateral wall opposite the ileocecal valve, it was difficult to visualize this area. It appeared there may be a small amount of inflammation there. This was biopsied with cold forceps. The entire colonic mucosa was then carefully circumferentially inspected upon slow withdrawal of the scope. The cecum, ascending, transverse, and descending colon were all normal. In the sigmoid colon, there was mild diverticular disease. The rectum and canal were normal. There was a thrombosed external hemorrhoid present at the canal. The patient tolerated the procedure well with no complications. Postoperatively, the patient was transferred to the recovery room in stable condition.
Colonoscopy Sample #2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Abdominal pain.
2. Chronic diarrhea.
POSTOPERATIVE DIAGNOSIS: Descending colon polyp.
PROCEDURE PERFORMED: Colonoscopy with biopsy.
SEDATION: MAC anesthesia.
PREPARATION: Fair with semisolid stool present throughout the colon. The majority was able to be washed off.
DESCRIPTION OF PROCEDURE: The patient was placed in the left lateral decubitus position. The Olympus video colonoscope was passed under direct visualization into the rectum. On retroflexion view in the rectum, no internal hemorrhoids or masses were seen. The remainder of the rectum was normal. The sigmoid colon was normal. In the proximal descending colon, there was an approximately 9 mm sessile polyp. This was cold biopsied and appeared to have been removed completely. The remainder of the descending colon was normal. The transverse, ascending colon, and cecum were normal. The ileocecal valve and appendiceal orifice were identified and were normal.
SPECIMENS: Descending colon polyp.
COMPLICATIONS: No immediate postprocedure complications.
IMPRESSION: Descending colon polyp. Otherwise, normal colonoscopy. The etiology of the patient’s diarrhea is unclear. It is possible this may be irritable bowel syndrome. However, we will continue further evaluation.
RECOMMENDATIONS:
1. Will await biopsy results.
2. Will obtain a small bowel follow-through.
3. If this is an adenomatous polyp, we would recommend repeat colonoscopy in two years.
Colonoscopy Sample #3
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Multiple medical problems, presents today for a screening colonoscopy.
POSTOPERATIVE DIAGNOSES:
1. Colon polyps.
2. Lipoma.
3. Small internal hemorrhoids
PROCEDURE PERFORMED: Colonoscopy with hot snare polypectomy, cold snare polypectomy, and cold forceps biopsy.
ANESTHESIA: Monitored anesthesia care per the anesthesiology department.
CONSENT: The risks and benefits of the procedure were discussed in detail with the patient and all questions were answered. An informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was placed in the left lateral decubitus position and sedated. A rectal exam was initially performed that revealed some mild rectal prolapse. The video endoscope was then inserted through the rectum and advanced to the cecum under direct visualization without any difficulty. The cecum was identified by noting both the appendiceal orifice and ileocecal valve, and picture documentation was obtained. The scope was then slowly withdrawn. The colonic mucosa was closely inspected. The colon prep was good. The visualized mucosa in the cecum appeared grossly normal. In the proximal ascending colon, a 3 mm polyp was noted and removed in entirety with cold forceps biopsy. Remainder of the visualized mucosa in the ascending colon appeared grossly normal. In the mid transverse colon, a 2 mm polyp was noted and removed in entirety with cold forceps biopsy. In the distal transverse colon, a 7 mm polyp was noted and removed with a cold snare technique. The polyp specimen was easily retrieved. In the splenic flexure, a 1 cm lipoma was noted. The scope was then withdrawn to the descending colon, and in the mid descending colon, two polyps ranging between 5 to 6 mm in size were noted, both removed via cold snare polypectomy and the specimens were retrieved. The visualized mucosa in the sigmoid colon appeared grossly normal. The scope was then withdrawn from the rectum. A 1.5 cm sessile polyp was noted in the rectum. This was removed via hot snare polypectomy. The polyp specimen was easily retrieved. A good coagulation was also achieved. Retroflexion was then performed in the rectum, which revealed small internal hemorrhoids. Air was then removed from the patient’s rectum and the scope was then withdrawn. The patient tolerated the procedure well. There were no apparent complications noted.
IMPRESSION:
1. Colon polyps.
2. Lipoma.
3. Small internal hemorrhoids.
POSTOPERATIVE RECOMMENDATIONS: We will follow up on the biopsy results. If the colon polyps return as adenomatous, the patient will need a repeat colonoscopy in approximately three years. We will also encourage the patient to increase her dietary fiber for her small internal hemorrhoids. We will advise the patient to call back in one week to get the biopsy results and to hold off on all aspirin, NSAID, Plavix, and Coumadin products for approximately two weeks. The patient should follow up with her primary care physician on her routine scheduled appointment, and she could follow up with GI as needed.
