Endoscopy
36 results
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Benign Disease- A 44-year-old man with known stricturing gastroduodenal Crohn’s disease with prior dilations who is receiving maximal medical therapy is admitted for increasing upper abdominal pain, nausea, vomiting, and weight loss. On endoscopy, obstructing duodenal stricture is noted. The esophagogastroduodenoscopy scope could not traverse this area. After nasogastric decompression, his best treatment option is:
- A 60-year-old woman is due for colorectal cancer screening and adamantly refuses colonoscopy. What is a recognized alternative to colonoscopy?
- A 47-year-old male patient with a history of ulcerative colitis, who is currently taking vedolizumab, presents for routine screening colonoscopy. He has mild proctosigmoiditis, and a 5-mm semipedunculated polyp is noted in the sigmoid colon. What is the best management approach for this polyp?
- A 43-year-old morbidly obese man is undergoing a Hartmann procedure for Hinchey IV perforated diverticulitis. Two days postoperatively, the ostomy has retracted below the skin and appears purple. The patient remains afebrile and hemodynamically normal without peritonitis. Intubation of the colostomy with a test tube reveals black mucosa proximal to the fascia. What is the next step in management?
- You are asked to evaluate a 63-year-old woman with rectal bleeding 2 days after she underwent endovascular abdominal aortic aneurysm repair. What is your next best diagnostic step?
- A 75-year-old man presents with a 1-week history of progressive abdominal distention and a 2-day history of obstipation. He is afebrile and his vital signs are within normal limits. On examination, he has massive abdominal distention and there is tympany to percussion, but no signs of peritonitis. Computed tomography reveals a large bowel obstruction with a whirl sign on the left side of the abdomen. There are no signs of bowel ischemia or perforation. What is the best next step in management?
- A 65-year-old man receiving long-term nonsteroidal treatment for arthritis presents to the emergency department with brisk bright red rectal bleeding and a blood pressure of 90/40 mm Hg. Intravenous fluid resuscitation has started. What is the best next step in evaluating the bleeding source?
- A 75-year-old woman without a history of liver disease or anticoagulant use is admitted to the intensive care unit with lower gastrointestinal bleeding. Findings of computed tomography angiography of the abdomen and pelvis and upper endoscopy are negative. Colonoscopy shows blood throughout the colon, but was unable to localize a definite source. A colonoscopy report from 3 years ago shows a 5-mm ascending colon tubular adenoma and sigmoid diverticulosis. In the past 48 hours, she has required transfusion of 6 units of packed red blood cells for ongoing bleeding. Digital examination and anoscopy show no significant anorectal pathology. The patient is hypotensive, requiring 2 vasopressors, and with tachycardia to 115 beats/min. What is the best next step in management?
- A 65-year-old man presents with abdominal pain, 15-lb (6.8-kg) weight loss, rectal bleeding, diarrhea, and joint pain. He had recently started taking prednisone for rheumatoid arthritis. On endoscopy, he is noted to have mucosal friability and ulcerations with pseudopolyps in the descending colon with rectal sparing. His terminal ileum is normal. Which finding is associated with a diagnosis of Crohn’s disease?
- A 26-year-old man with pan-colonic ulcerative colitis was diagnosed during a diagnostic colonoscopy 3 years ago. His disease is currently controlled with adalimumab treatment. He has no family history of colorectal cancer and no liver disease. When should he undergo colonoscopy for dysplasia surveillance?
- A 28-year-old man with a history of ulcerative colitis undergoes a total proctocolectomy with stapled ileal pouch–anal anastomosis. Six months after surgery, he presents with urgency, increased stool frequency, and bloody bowel movements. Endoscopic examination findings are shown (Figure A and B). What is the best next step in management?
- A 30-year-old woman with a history of perianal Crohn’s disease has had a seton in place for transsphincteric fistula for the past 2 months. She is also taking infliximab for medical management of her Crohn’s disease with no active proctitis seen on recent endoscopy. Ultrasonography shows 50% involvement of the sphincter complex with no undrained abscess or high blind tracts. What is the most appropriate management approach for her fistula?
- You are referred a 15-year-old boy with stricturing Crohn’s disease that is limited to the small intestine. He was initially treated with infliximab with moderate improvement in his symptoms. What is your best recommendation to monitor his disease activity?
- A 35-year-old man with ulcerative colitis underwent an ileal pouch–anal anastomosis. Eight weeks after surgery, contrast enema and pouchoscopy demonstrate a normal pouch and a patent anastomosis. No leakage from the pouch was noted on radiography. He underwent an uneventful ileostomy takedown. He initially did well but 6 weeks postoperatively he presents with pelvic pain, fevers, and increased pouch output. Computed tomography of the abdomen and pelvis reveals a pelvic abscess high in the pelvis with a normal pouch–anal anastomosis. An image-guided percutaneous drain is placed and the patient is treated with antibiotics. A sinogram 6 weeks later demonstrates a persistent fistula to the pouch. What is the appropriate management for this patient?
- A 35-year-old woman presents to the emergency department with a history of profuse watery diarrhea, crampy abdominal pain, and vomiting several days after eating oysters. Her laboratory findings are normal except for a mildly elevated white blood cell count, sodium 129 mEq/L (129 mmol/L), chloride 85 mEq/L (85 mmol/L), and potassium 3.2 mEq/L. Stool cultures are positive. Which pathogen is likely associated with this presentation?
- A 56-year-old man returns from a camping trip during which he drank water from a river. He now reports nausea, abdominal pain, and grossly nonbloody stools that float. A stool test for pathogens is indeterminate. The most appropriate next diagnostic test is:
- A 26-year-old man presents with watery diarrhea 4 weeks after undergoing autologous stem cell transplantation. He reports having over 10 bowel movements per day and his symptoms are progressive. He also complains of nausea and rash around his ears and shoulder. What is the most likely etiology?
- A 70-year-old man underwent external beam radiation for prostate cancer 2 years ago. He now presents with several episodes of bright red blood per rectum. Endoscopy reveals diffuse telangiectasias throughout the rectum. What is the next step in management?
- A 54-year-old woman with a 22-year history of ulcerative colitis undergoes screening colonoscopy. Results of all previous colonoscopies have been negative for dysplasia. In the ascending colon, a flat polyp is resected. Pathology reveals low-grade dysplasia in a background of quiescent (inactive) colitis. What is the most appropriate next step in management?
- A 76-year-old woman presents with a history of CHF to the hospital with abdominal pain of 24 hours’ duration and bloody diarrhea. Her temperature is 98.6°F (37.0°C), heart rate 90 beats/min, white blood cell count 16,000/mL (16´109/L), and blood pressure 110/70 mm Hg. Computed tomography imaging is ordered (Figure); Her abdomen is tender but without peritoneal signs. Colonoscopy shows patchy, superficial areas of ulceration and sloughing in the transverse colon. The best next treatment for this patient is which of the following?
- The quality metric for endoscopists that highly correlates with reduced interval colon cancer incidence and death is:
- A 55-year-old man with a 20-year history of medically refractive ulcerative pancolitis and primary sclerosing cholangitis undergoes a 2-stage total proctocolectomy with ileal pouch–anal anastomosis. He underwent a mucosectomy and hand-sewn anastomosis. The final pathology report reveals multifocal low-grade dysplasia. When would you perform pouchoscopy?
- A 78-year-old woman comes to the emergency department with a long history of chronic constipation and obstipation, nausea, abdominal pain, and distention for the past 5 days. Physical examination reveals abdominal distention with bilateral lower abdominal discomfort and fullness. On digital rectal examination, fecal impaction is noted and an attempt at manual disimpaction is unsuccessful. Computed tomography shows the findings in the Figure. The best next step in management for this patient is:
- Malignancy
- A healthy 3-month-old infant is undergoing a routine well-baby examination at his pediatrician’s office. His parents are concerned about the strong familial history of colon cancer in most members of the father’s family diagnosed before age 35 years. Which finding on examination would alert the pediatrician to a possible diagnosis of familial adenomatous polyposis?
- A 17-year-old boy with a family history significant for colonic polyps presents with bleeding per rectum and anemia requiring blood transfusion. Upper endoscopy and colonoscopy showed 10 polyps distributed in the stomach, duodenum, colon, and rectum. Pathologic findings on biopsy of the polyps are shown (Figs 1, 2, and 3). What is the gene responsible for this syndrome?
- A 60-year-old man presents for his postoperative visit 1 month after colon resection for stage II adenocarcinoma. Preoperative colonoscopy was otherwise unremarkable. When should surveillance colonoscopy be performed?
- A 67-year-old man recently underwent a colonoscopy with resection of a 1.2-cm pedunculated colon polyp from the sigmoid colon. The area from which the polyp was completely removed was marked with ink. Pathology showed well-differentiated adenocarcinoma invading into the submucosa of the stalk, with a 2-mm margin. No lymphovascular invasion was noted. What is the optimal management for this lesion?
- A 50-year-old woman is found to have a 7-mm submucosal yellow lesion in the distal rectum on screening colonoscopy. There is no pillow sign. What is the most likely diagnosis?
- A 57-year-old man is found to have a submucosal mass in the distal rectum on colonoscopy. Biopsy reveals spindle cells which stain positive for CD117 on immunohistochemistry. The lesion is posterior and 5 cm from the anal verge on rigid proctoscopy. Magnetic resonance imaging measures the size of the lesion as 1.3 cm with extension into the muscularis propria. What is the appropriate treatment?
- A 60-year-old woman presents with synchronous colon cancers in her cecum and sigmoid colon. Her brother had colorectal cancer at age 45 years. Testing reveals an MSH6 germline mutation. In addition to a total colectomy with ileorectal anastomosis, which of the following is most appropriate?
- Perioperative
- A 60-year-old woman with a history of incomplete colonoscopy related to diverticulosis, redundant colon, and “looping” is referred to you. You encounter the same difficulty as the prior endoscopist and are unable to complete the colonoscopy. What is the best next management option?
- A 65-year-old man with a history of rheumatic heart disease is being evaluated in preparation for his first screening colonoscopy. He is otherwise at average risk for colorectal cancer and has been told by his dentist that he needs antibiotics before all surgical procedures. Review of his medical record reveals a recent echocardiogram demonstrating mild thickening of the mitral valve leaflets and mild mitral regurgitation. He has no history of chronic kidney disease. The most appropriate recommendation is that:
- A 60-year-old man with a history of myocardial infarction treated with 2 drug eluting stents 6 months ago presents for evaluation for endoscopic polypectomy. His screening colonoscopy demonstrated 4 tubular adenomas ranging from 5 to 8 mm but resection was not attempted because of his current aspirin and clopidogrel intake. When should he undergo endoscopic polypectomy and how should his medications be adjusted?
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- Anorectal Disease