REASON
PROCEDURE: Colonoscopy.
INDICATIONS
A 29-year-old male with previous established Crohn's colitis elsewhere transferred to FMC Butner. I am to assess disease activity and extent of disease.
PROCEDURE IN DETAIL
Timeout was called. Consent signed. Examination of the perineum and rectum were normal. The preparation was adequate. IV sedation administered. The forward-viewing colonoscope was advanced to the cecum with intubation of the terminal ileum. Upon withdrawal, the following findings were noted.
FINDINGS
Ileum: The distal ileum was normal. No ileocolitis. Crohn disease seen. Biopsies were taken for confirmation of benign pathology.
Cecum and ascending colon: The cecal cap is relatively spare with normal vascular cascade identified. No ulcerations or scarring. No polyps observed. Beginning in the proximal ascending colon, there was evidence of burnt-out colitis, scar tissue was noted. Loss of normal landmarks. No vascular cascade seen. No active ulcerations. Biopsies were obtained from the right …show more content…
No active disease. Biopsies obtained. In the left colon there was an area of relatively sparing confined to the proximal sigmoid.
Rectum and sigmoid colon: Relatives focal area of sparing the sigmoid colon but normal vascular cascade seen. Then more distally more disease activity seen with scarring and then more distally in the distal sigmoid and rectum there was mild colitis noted. There is rectal involvement with granularity, contact bleeding, and ulcerations seen. Biopsies obtained. The procedure was terminated.
IMPRESSION
Chronic colitis.
It is difficult to state for certain from today's exam whether or not this is Crohn's disease or ulcerative colitis. The disease is confined to the colon, however. The distal ileum is normal. Biopsies were obtained and there were no
PROCEDURE: Colonoscopy.
INDICATIONS
A 29-year-old male with previous established Crohn's colitis elsewhere transferred to FMC Butner. I am to assess disease activity and extent of disease.
PROCEDURE IN DETAIL
Timeout was called. Consent signed. Examination of the perineum and rectum were normal. The preparation was adequate. IV sedation administered. The forward-viewing colonoscope was advanced to the cecum with intubation of the terminal ileum. Upon withdrawal, the following findings were noted.
FINDINGS
Ileum: The distal ileum was normal. No ileocolitis. Crohn disease seen. Biopsies were taken for confirmation of benign pathology.
Cecum and ascending colon: The cecal cap is relatively spare with normal vascular cascade identified. No ulcerations or scarring. No polyps observed. Beginning in the proximal ascending colon, there was evidence of burnt-out colitis, scar tissue was noted. Loss of normal landmarks. No vascular cascade seen. No active ulcerations. Biopsies were obtained from the right …show more content…
No active disease. Biopsies obtained. In the left colon there was an area of relatively sparing confined to the proximal sigmoid.
Rectum and sigmoid colon: Relatives focal area of sparing the sigmoid colon but normal vascular cascade seen. Then more distally more disease activity seen with scarring and then more distally in the distal sigmoid and rectum there was mild colitis noted. There is rectal involvement with granularity, contact bleeding, and ulcerations seen. Biopsies obtained. The procedure was terminated.
IMPRESSION
Chronic colitis.
It is difficult to state for certain from today's exam whether or not this is Crohn's disease or ulcerative colitis. The disease is confined to the colon, however. The distal ileum is normal. Biopsies were obtained and there were no