PROCEDURE: Colonoscopy with Polypectomy

PROCEDURE: Colonoscopy with polypectomy.

PREOPERATIVE DIAGNOSIS: Screening.

POSTOPERATIVE DIAGNOSIS: 1. Flat multiple polyps removed from cecum. 2. Diverticula. 3. Extremely angulated, tortuous, redundant colon.

HISTORY: This is a 66-year-old woman here for a screening colonoscopy, considered ASA-II class. Informed consent is obtained after discussion of procedure and risks in detail including those of bleeding, perforation, etc.

PHYSICAL EXAMINATION: A pleasant 66-year-old woman, HT 5 feet 4 inches, WT 154 pounds. Vitals stable. Lungs clear. Heart sounds are regular, S1 and S2. BP 110/70. Abdomen is soft without tenderness or mass.

DESCRIPTION OF PROCEDURE: Patient brought to the exam room, placed on the monitors, IV sedation used with Valium and Demerol. Digital rectal exam was done. The Olympus Video colonoscope was passed transanally, guided under direct vision through an extremely angulated rectosigmoid, sigmoid, descending colon, splenic flexure, transverse colon, hepatic flexure, into the ascending colon. Passage was very slow, arduous, and difficult with multiple maneuvers requires with abdominal counterpressure and scope manipulations. Eventually the scope was passed finally all the way to the base of the cecum with maximal difficulty. Cecum shows flat polyps, slightly pink, slightly raised above the surface, very subtle. There are three in number, range in size from 5 to 10 mm. Polyps are removed in a piecemeal fashion and multiple fragments obtained. Good cautery effect noted. Scope is withdrawn. Ileocecal valve was normal. Ascending colon, hepatic flexure, transverse colon, and splenic flexure were normal. Descending colon was normal. Sigmoid showed diverticula. Rectum was normal. Retroflexed views were normal. Scope was removed.

RECOMMENDATIONS: Patient will be on a strict post-polypectomy protocol. Repeat colonoscopy may be needed in two to three years based on histology. If this is all hyperplastic, then we may be able to wait for five years.

- CPT Code: 45380