PROCEDURE: Colonoscopy with biopsy and polyp removal.

PREOPERATIVE DIAGNOSES: Diarrhea, anemia.

POSTOPERATIVE DIAGNOSES:

1. Small polyp removed from proximal descending colon.

2. Normal colon mucosa biopsied.

3. Post biopsy bleeding requiring Endoclip usage.

4. Extremely redundant colon making it technically a difficult study.

HISTORY: This is a 72-year-old lady with anemia and diarrhea. Hemoglobin 7.2, requiring transfusion. Previous EGD at Community Hospital showed a gastric ulcer. Small bowel biopsies were not done. She is here for colonoscopy. Informed consent obtained. Considered ASA class II.

PHYSICAL EXAMINATION:

VITAL SIGNS: She weighs 177 pounds.

LUNGS: Clear.

HEART: Regular.

MOUTH: Dentures noted.

Mallampati score 3.

PROCEDURE: Patient brought to exam room, placed on the monitors, IV

sedation is used with Versed and Demerol eventually being a total of 4.5 and 70 mg respectively. Digital rectal exam was done. Olympus video colonoscope was passed transanally, guided under direct vision through an extremely redundant and angulated sigmoid and descending colon. Abdominal counterpressure was used extensively to get to cecum. Ileocecal valve was seen, but could not be intubated. Scope was withdrawn. Prep was excellent. Careful inspection carried out. Good views obtained. Cecum and ascending colon were normal. Ascending colon biopsies were taken to rule out microscopic colitis, etc. Transverse colon was normal. Descending colon proximally near splenic flexure showed a subtle polyp, slightly raised above the surrounding mucosa, measuring about 3 mm in diameter, pinkish in color. This was photographed and removed with cold biopsy forceps. There was brisk oozing, which persisted after irrigation and tamponade, so EndoClips were used and initially this was without success. Eventually, 4 EndoClips were used in total to completely stop the oozing. This was irrigated, washed, and observed for 5 minutes without bleeding noted. Scope was withdrawn. Rest of descending colon, sigmoid, and rectum were normal. Retroflexed views are normal. The scope was removed. Withdrawal time was 13 minutes.

RECOMMENDATIONS: Patient will be notified of biopsy results and she will be followed up in the clinic. Celiac disease antibodies were also

ordered. Further stool workup may be needed, although in the hospital she had cultures, leukocytes, and C. diff toxin, which were negative.

CPT Code: 45380 Bleeding caused by polyp removal. Can not code for control of bleeding.