Consult Gastroscopy Colonoscopy

DATE: 1 November 2024 PROCEDURE: "Gastroscopy and Colonoscopy" PRE-PROCEDURE DIAGNOSIS: - Chronic abdominal pain - Iron deficiency anaemia - Suspected inflammatory bowel disease POST-PROCEDURE DIAGNOSIS: - Mild gastritis - Diverticulosis - Internal haemorrhoids HISTORY OF PRESENTING ILLNESS: Mrs. Jane Smith, a 55-year-old female, was referred by her General Practitioner due to a 6-month history of intermittent, crampy lower abdominal pain, often relieved by defaecation, associated with alternating constipation and loose stools. She also reported significant fatigue and recent investigations revealed iron deficiency anaemia. She denies any weight loss, fever, or rectal bleeding. Previous relevant procedures include a barium enema 5 years ago, which showed mild diverticulosis. Recent clinical events include a course of oral iron supplementation for her anaemia, which has slightly improved her fatigue but not her bowel symptoms. PAST GI HISTORY: - Mild diverticulosis (diagnosed via barium enema 5 years prior) - Occasional heartburn, controlled with over-the-counter antacids PAST HISTORY: - Hypertension (controlled with medication) - Type 2 Diabetes Mellitus (well-controlled with diet and metformin) - Hysterectomy (10 years ago for fibroids) MEDICATIONS: - Metformin 500mg, twice daily, oral - Ramipril 5mg, once daily, oral - Ferrous Sulphate 200mg, once daily, oral ALLERGIES: Penicillin (rash) FAMILY HISTORY: Patient's mother had a history of colon cancer diagnosed at age 70. Her father had Type 2 Diabetes and hypertension. No other significant family history of gastrointestinal diseases or autoimmune conditions. SOCIAL HISTORY: Mrs. Smith is a retired school teacher, living with her husband in a detached house. She is mobile and independent. She reports occasional social alcohol consumption (1-2 units per week) and quit smoking 10 years ago (previously 20 pack-years). She denies any illicit substance use. PHYSICAL EXAM: "The abdomen was soft, non-tender, with no hepatosplenomegaly or masses. Cardiovascular, respiratory, lymph node, and dermatological examinations were normal." INVESTIGATIONS: - 15/10/2024: Hb 9.8 g/dL, Ferritin 8 ng/mL (consistent with iron deficiency anaemia) - 01/09/2024: Stool studies negative for occult blood and infection CONSENT: "Informed consent was obtained after having reviewed the rationale and alternatives for the procedure as well as its risks, which include but are not limited to: sedation-related adverse effects, aspiration, post-procedural chest or abdominal discomfort, less than one percent risk of perforation with dilation potentially requiring surgical intervention and infection." SEDATION: "Intravenous conscious sedation consisting of midazolam 3 mg and fentanyl 50 mcg." PROCEDURE: "Gastroscopy: After a time out, with the patient in the left lateral decubitus position, the gastroscope was inserted into the oropharynx and carefully advanced with direct visualization to the level of the cricopharyngeus. Esophageal intubation was performed without difficulty. The gastroscope was gradually advanced and the entire esophageal mucosa was carefully visualized. The gastroscope was further advanced into the stomach and the mucosa of the gastric fundus, body, and antrum were slowly surveyed. The gastroscope was subsequently advanced into the duodenum for evaluation of the first and second portions. Satisfactory mucosal views were achieved with the use of irrigation and suctioning of all pools of residue, mucus and fluid, and retroflection. The gastroscope was removed. The patient tolerated the procedure well. Colonoscopy: The patient was repositioned. Digital rectal examination was performed. An Olympus colonoscope was inserted into the rectum and advanced with the use of water insufflation and positional changes to the level of the cecal pole. Normal cecal pole landmarks were identified with clear visualization of the ileocecal valve and appendiceal orifice. Photographs were obtained. The colonoscope was carefully withdrawn. Satisfactory mucosal views were achieved with the use of dynamic positional changes, irrigation and suctioning of all pools of residue, mucus and fluid, segment reassessment, and retroflection. The colonoscope was removed and the patient was returned to the recovery room having tolerated the procedure well." QUALITY INDICATORS: "1. Bowel prep: Excellent, no significant faecal residue 2. Extent of examination: Caecum reached, ileum intubated for 5cm 3. Withdrawal time: 9 minutes 4. Technical difficulties: None 5. Unplanned events: None" ASSESSMENT AND PLAN: Mrs. Smith underwent a combined gastroscopy and colonoscopy for investigation of chronic abdominal pain and iron deficiency anaemia. Gastroscopy revealed mild antral gastritis, with biopsies taken. Colonoscopy showed scattered diverticula throughout the sigmoid and descending colon, as well as small internal haemorrhoids. The remainder of the colonic mucosa was unremarkable. Biopsies were taken from the stomach and colon to rule out microscopic colitis or other inflammatory conditions. The iron deficiency anaemia is likely multifactorial, potentially related to the gastritis and/or diverticular disease, although no obvious bleeding source was identified endoscopically. The plan is to await biopsy results. She will be started on a Proton Pump Inhibitor for 8 weeks for the gastritis. Follow-up with her GP in 4 weeks to review iron levels and symptoms, and a gastroenterology follow-up will be arranged once biopsy results are available to discuss further management, which may include dietary advice for diverticulosis.