DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Bright red blood per rectum.
2. Gastrointestinal bleeding.
3. Anemia requiring transfusion.
POSTOPERATIVE DIAGNOSIS: Pandiverticulosis of the colon.
PROCEDURE PERFORMED: Colonoscopy.
ANESTHETIC: Sedation.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female with a history of bright red blood and melena. Her hemoglobin on admission was less than 7.4. She required transfusion. She was placed in the ICU. The bleeding apparently slowed, and she reported a colonoscopy over five years ago with history of diverticulosis but no history of bleeding or diverticulitis. We consented her for colonoscopy.
DESCRIPTION OF PROCEDURE: The patient was brought into the endoscopy suite. She was attached to all appropriate monitoring equipment. IV sedation was administered. She was positioned in the left lateral decubitus position. A rectal exam was performed. Rectal tone was normal. There were no abscesses or fissures. She had atrophic hemorrhoidal tags.
Once rectal exam was completed, a well-lubricated video colonoscope was advanced into the rectal vault. The patient was noted to have poor prep with greenish stool coating all surfaces of the mucosa and occasional small pieces of fecal material. The scope was advanced beyond this initial finding and irrigation/aspiration was performed as the scope was advanced into the sigmoid colon. Multiple wide-mouthed diverticula. No evidence of bleeding was encountered. The descending and transverse colon were cannulated. Multiple diverticula but no polyps, tumors or evidence of bleeding. The right colon was also cannulated; however, we were unable to manipulate the scope into the cecum.
The scope was used to irrigate and wash all mucosal surfaces and slowly withdraw the scope while inspecting these surfaces. No abnormalities other than the above-mentioned diverticulosis were found. There was no evidence of any bleeding. No polyps. No tumors. No AV malformations.
The scope was then withdrawn back through the transverse, descending, and sigmoid colons. Photographic documentation of the diverticula was obtained. The scope was retroflexed in the rectal vault and mild, noninflamed, nonbleeding hemorrhoids were noted. The scope was then used to decompress the colon.
The patient was allowed to awaken. She tolerated the procedure well. There were no complications.
IMPRESSION: Colonoscopy with pandiverticulosis and mild internal hemorrhoids.
RECOMMENDATIONS: Resume high-fiber diet. Avoid nuts and seeds. Iron replacement. Follow up p.r.n. and/or recurrent bleeding.
