Endoscopy
34 results
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Perioperative- A 54-year-old woman presents 6 months after a sigmoid partial colectomy performed for diverticular disease. She describes increasing symptoms of abdominal pain, constipation, and cramping. Endoscopy shows narrowing at the level of the colorectal anastomosis (see figures below). The most appropriate next step in management is
- During an investigation of an infection outbreak in your endoscopy unit, you are worried about the role of biofilm. What step is critically important to be performed in a timely fashion during the processing of flexible scopes to prevent the formation of a biofilm?
- On postoperative day 2, after elective sigmoid resection and primary anastomosis for diverticular disease, a patient reports multiple bright red bloody stools that persists over the next 12–24 hours. Initially, he had a heart rate of 110 and blood pressure of 100/50 mmHg, and he sustained a hemoglobin drop from 12 g/dL to 8 g/dL, requiring transfusion. After resuscitation, what is the best next step in management?
- A 65-year-old man is scheduled to undergo an average risk screening colonoscopy. He takes apixaban daily for atrial fibrillation. What is the best course of action in him?
- Benign Disease
- A 56-year-old man with a remote history of uncomplicated sigmoid diverticulitis presents with pneumaturia, fecaluria, and frequent urinary tract infections. Colonoscopy showed sigmoid diverticulosis. Computed tomography (CT) of the abdomen and pelvis showed air in the bladder. Cystoscopy showed 1.5 cm defect in the bladder. The best next step in the management of this patient is
- For quality assurance of the completeness of a colonoscopy, it is mandatory to achieve which of the following?
- An 81-year-old nursing home resident presents at the emergency department with acute onset of abdominal pain and nausea. She has a history of constipation, and her last bowel movement was 4 days ago. On physical examination, the patient is distended but not tender. Laboratory results, including lactate, are within normal limits and abdominal X-ray demonstrates a coffee bean sign. What is the best next step in management?
- A 56-year-old man presents with massive rectal bleeding. He has a history of alcohol abuse. Which of the following is next indicated?
- A 75-year-old man with no significant medical history presents to the emergency department with recurrent bright red blood per rectum. Previous workup included computed tomography angiography (CTA), upper endoscopy, and anoscopy, which were all negative. Previous colonoscopy showed pancolonic diverticulosis with blood throughout the colon. He is now receiving his fifth unit of packed red blood cells. His blood pressure remains 80/50 mmHg despite resuscitation. What is the best next step in this patient’s management?
- A 48-year-old healthy patient is undergoing routine screening colonoscopy. During withdrawal, a 4-mm polypoid lesion is noted in the mid-ascending colon. Optimal removal of this lesion is obtained with
- A 45-year-old man has an 8-year history of moderate-to-severe chronic ulcerative colitis (UC), managed with biologics and with good symptom control. He has no other notable medical or surgical history. His last colonoscopy was performed 1 year ago, with random biopsies demonstrating low-grade dysplasia. The patient is concerned about the development of colorectal cancer due to his history and is here for surveillance endoscopy. What is the best next step in this patient’s management?
- A 29-year-old man was diagnosed with ulcerative pancolitis 5 years ago and has been maintained on mesalamine. When should he be recommended to initiate surveillance colonoscopy to assess for dysplasia?
- A 32-year-old patient on inflixmab for maintenance therapy of ulcerative colitis (UC) is admited to the hospital with abdominal pain, six bloody stools daily, temperature of 38 ºC, and heart rate of 100 beats per minute. Colonoscopy demonstrates pancolitis with erythema, ulcerations, and scattered pseudopolyps. The best next step in treatment is intravenous (IV)
- A 36-year-old patient with ulcerative colitis (UC) underwent total proctocolectomy with ileal pouch anal anastomosis (IPAA) 3 years ago. The patient presents now with lower abdominal discomfort that is associated with bloody loose stools. Endoscopy shows erythematous friable rectal cuff with deep ulcers. The rest of the pouch appears normal. What is the most appropriate treatment?
- A 25-year-old man with ulcerative colitis (UC) is 2 years status post restorative proctocolectomy with J-pouch. He was doing well until 5 weeks ago, when he developed moderate pelvic abdominal pain and a significant increase in the frequency of his bowel movements (>10/day). Dietary changes did not improve the symptoms. Pouchoscopy revealed moderate severity diffuse erythema and friability, with exudates and erosions. Stool cultures are negative for any growth. The best next step in treatment for this patient is
- A 55-year-old man with a history of ulcerative colitis (UC) diagnosed in his early 20s presents with a new diagnosis of distal rectal moderately differentiated adenocarcinoma. Mismatch repair (MMR) protein expression is intact; routine surveillance endoscopy showed a mass starting ~2 cm from the anal verge with all other biopsies negative for dysplasia. Laboratory results reveal unremarkable levels of carcinoembryonic antigen (CEA), comprehensive metabolic panel (CMP), and complete blood count (CBC). Systemic staging is negative for metastatic disease. Local staging with magnetic resonance imaging (MRI) reveals a T3N1 lesion. Based on a multidisciplinary tumor board discussion, the patient is planned for total neoadjuvant chemotherapy with upfront chemoradiation followed by consolidation chemotherapy. After this therapy is completed, what is the optimal surgical course for this patient?
- A 25-year-old man with a history of medically refractory ulcerative colitis (UC) and who has undergone a total abdominal colectomy with end ileostomy now presents for his second stage operation of a completion proctectomy, ileoanal pouch anastomosis, and diverting loop ileostomy. What is considered optimal J-pouch length?
- A 34-year-old otherwise healthy woman, who underwent total abdominal colectomy with end ileostomy 1 year ago for fulminant Crohn’s disease colitis, presents to the office with ongoing bloody mucoid discharge per rectum and tenesmus. On examination, her abdomen is unremarkable with end ileostomy. Ileostomy is healthy and pouches well. Rectal examination is remarkable for normal perineal skin, normal tone, and absence of fistula and fissure. She has been through four different biologics. Endoscopy shows deep ulcers in the rectum with mucosal friability. She has bothersome mucoid anal discharge multiple times per day and wishes to know whether this can be resolved. Her small bowel disease was previously active and is now quiescent on entyvio. What is the best next option in her management?
- A 30-year-old woman is status post total proctocolectomy, ileal J pouch-anal anastomosis and loop ileostomy for refractory ulcerative colitis two months ago. She now presents for follow-up to discuss elective takedown of her loop ileostomy. As part of her workup a gastrograffin enema is obtained (see figures). The best next step is
- A 46-year-old man presents as an inpatient consult for persistent watery diarrhea, nausea, and abdominal cramps. The patient has a history of acute myeloblastic leukemia and received an allogeneic stem cell transplant 6 months ago. The patient notes compliance with his immunosuppression medications. The most common cause of diarrhea in this patient is most likely caused by which of the following?
- A 75-year-old woman presents with abdominal pain and multiple episodes of diarrhea starting 24 hours prior to presentation. She has had two episodes of Clostridium difficile (C. diff) infection (CDI) in the past 3 months. Stool studies show positive C. diff toxin enzyme immunoassay. Which of the following is the best next step in the treatment of this patient?
- A 67-year-old man with a history of uncontrolled hypertension, heavy cigarette smoking, and chronic renal insufficiency undergoes an open repair of a leaking abdominal aortic aneurysm (AAA). On postoperative day 2, he has passage of bright red blood per rectum associated with increased abdominal pain and leukocytosis. On examination, he has tenderness in the left lower quadrant without peritoneal signs. His vital signs show a blood pressure of 90/50 mmHg and a heart rate of 110 beats per minute. You initiate intravenous (IV) fluid resuscitation and obtain computed tomography (CT) of the abdomen and pelvis, which revealed a thickened sigmoid colon with no pneumoperitoneum. You initiate bowel rest and IV antibiotics. The best next step is
- A 50-year-old man with a 15-year history of ulcerative colitis (UC) is undergoing a surveillance colonoscopy. You find mild active colitis from the rectum to the splenic flexure, normal colon proximally, and a small 5-mm inflammatory polyp in the sigmoid colon. What is the recommended next step to take at this time?
- A 62-year-old man presented with left lower quadrant pain. Computed tomography (CT) showed sigmoid diverticulitis with a microperforation and a 1.5-cm intramural abscess. He had a similar episode 1 year ago. His last colonoscopy was 10 years ago, and it was normal except for sigmoid diverticulosis. After conservative management, the inflammation resolves and the patient presents to your clinic for follow-up. The recommended next step in management is
- Pelvic Floor
- Malignancy
- A 23-year-old woman who was recently diagnosed with familial adenomatous polyposis (FAP) has three younger siblings. Her siblings underwent genetic counseling and testing. One of her siblings, aged 8, has the adenomatous polyposis coli (APC) gene mutation. When should endoscopic screening begin in her asymptomatic 8-year-old sibling?
- A healthy 25-year-old woman with family history of familial adenomatous polyposis (FAP) does not wish to undergo genetic testing. She agreed to colonoscopy, which found more than 100 polyps throughout the colon and rectum. In addition to performing prophylactic proctocolectomy and ileoanal J pouch anastomosis, which additional examination is most likely to improve her survival?
- A 60-year-old patient undergoes an average-risk screening colonoscopy and is found to have a large sessile polyp on the left colon. What methods can you employ to evaluate the morphology of the lesion and its risk of harboring malignancy?
- A 78-year-old woman with coronary artery disease and congestive heart failure presents with symptoms of large bowel obstruction. Computed tomography (CT) shows a large obstructing descending colon mass with numerous hepatic and pulmonary lesions suggestive of metastatic disease. There is no evidence of bowel perforation or ischemia. Flexible endoscopy shows a large near complete obstructing carcinoma in the descending colon. Which of the following is the most appropriate next step?
- Anorectal Disease
- A 34-year-old male who engages in anal receptive intercourse presents to the clinic with a 2-week history of rectal pain, bright red bleeding, tenesmus, and persistent diarrhea. He has family history of Crohn’s disease. Urgent colonoscopy reveals normal ileum and colon but moderate proctitis with patchy ulcerations and copious amounts of mucus. Rectal cultures and biopsy results are pending. The most appropriate next step in management is
- A 24-year-old HIV–positive man, who reports having sex only with men, presents with rectal pain, bright red blood per rectum, and tenesmus. Flexible sigmoidoscopy shows inflammation limited to the rectum and perianal ulceration. What is the most likely cause of his proctitis?
- A 25-year-old patient presents having inserted a vibrator via anus. The device is not palpable on digital rectal examination (DRE) and appears above the level of the sacral promontory on imaging. There are no signs of peritonitis. What is the best recommendation for foreign body extraction?
- Colon and Rectal Surgery Educational Program (CARSEP)