DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Hemoccult-positive stools, melena and acute blood loss anemia, on anticoagulation therapy with aspirin, Plavix and heparin, not explained by upper endoscopic findings.
POSTOPERATIVE DIAGNOSES:
1. Large, extensive rectal prolapse, ischemic-type ulcerations with visible vessel and active bleeding, photocoagulated with ERBE argon laser for hemorrhage control.
2. Severe rectal prolapse.
3. Several benign-appearing colon polyps, the largest measuring 1.6 cm.
4. Moderate sigmoid diverticulosis with no acute diverticulitis.
PROCEDURES PERFORMED:
1. Colonoscopy to cecum.
2. ERBE argon laser photocoagulative ablation of a bleeding rectal ulcer visible vessel for hemorrhage control.
ENDOSCOPIST: John Doe, MD
PREP: Combination of Fleet Phospho-soda with GoLYTELY, generally very poor, requiring extensive and copious irrigation and lavage, markedly prolonging the patient’s procedure.
ANESTHESIA: Monitored anesthesia care.
PROCEDURE IN DETAIL: After informed consent had been obtained prior to sedation for upper endoscopy, the patient was kept in the semirecumbent position. Colonoscopy was performed with the patient on his back. Digital rectal examination revealed some narrowing of the anal sphincter, with tenderness. The finger was used as a guide to insert the Olympus video colonoscope through the anus into the rectum. A small amount of air was insufflated to distend the lumen. The scope was then advanced with moderate difficulty, proximally, due to the presence of extreme spasticity in the left colon area with moderate diverticulosis. There was no evidence of any diverticulitis noted within this area. The prep was poor throughout with large pools of liquid stool that required copious irrigation and lavage with aspiration. Using a push-pull technique, the cecum was finally reached, where the ileocecal valve and appendiceal orifice were both identified to verify location. The mucosa was inspected upon insertion of the scope and carefully re-inspected upon withdrawal of the scope. Retroflexion was not performed in the rectum due to extreme rectal spasticity and the presence of decreased rectal chamber size due to essentially circumferential, patchy, exudative, ischemic-type ulcerations that were seen in the context of rather severe rectal prolapse. One of these ulcerations, which was more distally located in the rectum and measured 1.6 cm, had a visible vessel and was actively bleeding. This ulceration was cauterized with an ERBE argon laser cautery unit at a setting of 40 watts of power, 1 liter per minute argon flow. There was cessation of bleeding. Also noted within the colon were several polyps. In the cecum was a sessile 1.6 cm polyp, which was not removed. Another 3 mm sessile benign-appearing polyp was seen in the fold in the hepatic flexure. Within the sigmoid colon, at approximately 30 cm, two sessile 4 to 6 mm benign-appearing polyps were seen. Another larger broad-based polyp, measuring between 1.5 cm and possibly 2 cm, was seen in the rectum at 15 cm. None of these polyps were removed due to the patient having been actively on aspirin, Plavix, heparin and requiring these. No biopsies were taken throughout the colon, as noted. Prior to withdrawal of the scope from the patient, air was removed from the colon. The patient tolerated the procedure well with no evidence of immediate complications. The patient was stable on transfer to the recovery area.
IMPRESSION:
1. The patient has Hemoccult-positive stools, melena, as well as blood loss anemia. They very well can be explained by the extensive rectal prolapse, ischemic-type ulcerations, one of which had a visible vessel and was actively bleeding requiring photocoagulation for bleeding cessation. These are chronic-appearing ulcers and they may very well be exacerbated by diarrhea with rectal prolapse.
2. Several adenomatous-appearing polyps, two of which were of substantial size, one measuring 1.6 cm in the cecum and second one of 1.5 or possibly 2 cm in rectosigmoid colon that has a significant risk of containing or developing into a malignancy. These were not removed or biopsied secondary to the patient being actively on aspirin, Plavix and heparin.
3. Moderate uncomplicated sigmoid diverticulosis.
RECOMMENDATIONS:
1. Bowel regimen for the patient’s rectal prolapse and ulcerations. Anticholinergic, antispasmodic therapy as well as fiber supplements and stool softeners will be initiated.
2. Possibly discontinue the Zosyn due to the patient’s recent diarrhea, which may be antibiotic associated, particularly in the absence of any pseudomembranes to suggest pseudomembranous colitis.
3. Careful monitoring for any continued significant bleeding in the context of continued aspirin, Plavix and heparin therapy.
4. Anticipate the colonoscopy to be rescheduled along with upper endoscopy for biopsies and polypectomies within approximately 6 months or sooner when the patient can be safely taken off his anticoagulation therapy.
