DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: History of intermittent bright red blood per rectum, status post ileocecal resection for Crohn’s disease.
POSTOPERATIVE DIAGNOSIS: History of intermittent bright red blood per rectum, status post ileocecal resection for Crohn’s disease.
PROCEDURE PERFORMED: Flexible colonoscopy to ileocolonic anastomosis.
SURGEON: John Doe, MD
ANESTHESIA: Intravenous Versed and fentanyl.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: This patient is status post prior ileocecal resection for Crohn’s disease and now presents with intermittent bright red blood per rectum noted primarily on the toilet paper, as well as within the toilet bowl. The patient’s weight has been stable, and the patient denies any abdominal discomfort or distention. The patient will now undergo planned flexible colonoscopy to the level of the ileocolonic anastomosis in order to evaluate distal small bowel and colon.
DESCRIPTION OF PROCEDURE: The patient was transported to the endoscopy suite and placed in the left lateral decubitus position. Following administration of intravenous Versed and fentanyl to achieve a satisfactory level of anesthesia, the flexible Olympus colonoscope was introduced transanally and threaded proximally through the sigmoid, descending, transverse, and remaining ascending colon to the level of the ileocolonic anastomosis. The anastomosis was widely patent and inspection of the ileal mucosa revealed mild cobblestoning without evidence of ulceration or bleeding.
The scope was then withdrawn through the ascending, transverse, and descending colon with mucosa again being carefully inspected. There was no evidence of Crohn’s colitis, polyps, or diverticulosis. The sigmoid and descending colon was tortuous secondary to adhesions from the patient’s prior surgical procedures, and the mucosa of the sigmoid colon and rectosigmoid colon was unremarkable. No diverticula were present and there no evidence of inflammatory bowel disease. The mucosa of the rectum was normal, and retroflexion of the scope revealed 2+ internal hemorrhoids without bleeding.
The scope was then withdrawn, and the patient appeared to tolerate the procedure well.
IMPRESSION AND RECOMMENDATIONS: The patient has evidence of mild Crohn’s disease within the ileum and no evidence of inflammatory bowel disease involving the colon. The patient has been instructed on topical care for internal hemorrhoids. It is recommended that the patient have followup colonoscopy in five years’ time.
