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Abstract: A 42-year-old patient came to the hospital with a recent feeling of abdominal pain and bloating with diarrhea, and was diagnosed with a small intestinal polyp after colonoscopy. After determining the treatment plan and communicating with the family and the patient, surgical treatment was determined, namely mucosal resection treatment under endoscopy. After the operation, the patient recovered well, and the symptoms of abdominal pain and distension were relieved, so he was discharged.
Basic information】Male, 42 years old
Disease Type】Small intestinal polyp
Hospital】The First Affiliated Hospital of Kunming Medical University
Date of consultation】April 2022
Treatment plan】Surgical treatment (endoscopic small intestine mucosal resection) + anti-infection treatment (penicillin sodium for injection) + rehydration and nutritional support (5% glucose injection)
[Treatment cycle] Hospitalization for 4 days, regular review for 3 months, 6 months and 1 year
Effectiveness of treatment】The patient’s abdominal pain and bloating were significantly relieved, stools returned to normal, and the condition was controlled
I. Initial consultation
More than 2 months ago, the patient came to the clinic because he felt abdominal pain and bloating. At first sight, the patient did not find any other abnormalities except for the unhealthy complexion, so he started to ask for details. The patient was 42 years old and a self-employed businessman. In the past 2 weeks, he felt abdominal pain and bloating, and the pain increased after eating spicy and cold food. On initial examination, the patient’s temperature was 36.5℃, blood pressure 118/73mmHg, respiration 16 times/min, and heart rate 69 times/min, all of which were normal. On examination, the patient’s pupils were equally large and rounded bilaterally, he was sensitive to light, his mouth was not cyanotic, his tonsils were not enlarged, his neck was not resistant, his hepatic and jugular venous reflux signs were negative, his thyroid gland was not enlarged, his trachea was in the center, his breath sounds were clear in both lungs, and no rales were heard. The abdomen was flat and soft, and there was no obvious mass on palpation and pain on pressure. To further confirm the diagnosis, endoscopic examination was performed, which showed a pile of mucosal tissue in the small intestine, and laboratory tumor markers showed no abnormalities.
II. Treatment process
After admission, the patient continued to improve blood routine, urine routine, blood glucose, blood lipids, liver and kidney function, electrolytes, C-reactive protein and other related tests, and the results were not significantly abnormal. After ultrasound examination, there were multiple polyps in the small intestine, and the fecal occult blood test showed positive, combined with outpatient colonoscopy, so the diagnosis of small intestinal polyps was further confirmed, and treatment was carried out immediately. After communicating with the patient and family, the patient was treated surgically. After a crumb-free diet for 2 days before surgery and laxative bowel cleansing 6-8 hours before surgery, the patient was treated with endoscopic small bowel mucosal resection on the third day of admission, and the small bowel polyps were removed. The patient was returned to the ward after the operation, and was routinely fasted with food and water for 24-48 hours, and was given intravenous penicillin sodium for injection to fight infection, and 5% glucose injection for intravenous rehydration and nutritional support. The patient’s condition was relatively stable, and he did not complain of abdominal pain, fullness and other discomforts, and was discharged on the fourth day after comprehensive evaluation.
III. Treatment effect
In the past 2 weeks, the patient felt pain and bloating in the abdomen, and the pain worsened after eating spicy and cold food. The patient cooperated with the doctor after admission and underwent active and effective treatment. After resection of small intestinal polyps, the patient did not feel any discomfort and returned to the ward and received other adjuvant treatments. After discharge from the hospital, the patient followed the doctor’s advice, took medication on time, and quit smoking and drinking. At the time of re-examination, the patient’s mental state was good, stool was back to normal, abdominal pain and abdominal distension had disappeared, the polyp had been completely removed by endoscopy, the surface of intestinal mucosa was smooth and soft, and the condition had been well controlled.
IV. Notes
We are glad that the patient was treated and the small intestinal polyp was successfully removed. After discharge from the hospital, the patient should keep a happy mood, pay attention to the combination of work and rest, moderate activity, and develop a regular and healthy lifestyle. From the day of discharge to the 7th day, we will have a semi-liquid diet, and from the 8th to the 14th day, we can transition to a normal diet, avoiding spicy and stimulating food, and regularly re-examining 3 months, 6 months and 1 year after surgery. If there is discharge with medicine, take it on time according to the doctor’s order. If there is abdominal pain, fever and other uncomfortable symptoms, delayed perforation may have occurred, and timely consultation should be made.
V. Personal insight
Patients with small intestinal polyps can usually achieve cure after treatment, but they also need regular follow-up checkups after surgery. Although small intestinal polyps are small problems, they should not be ignored because polyps include tumor polyps and non-tumor polyps, and tumor polyps are closely related to the occurrence of cancer and have a certain rate of malignancy, which is a pre-cancerous lesion or state, so they need to be paid attention to and prevented in advance. We hope we can all develop good living habits and have regular medical checkups.