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Abstract: A 55-year-old male patient presented to a local hospital with abdominal pain and distension and was found to have a mass in the intestine and a polyp in the colon on ultrasonography. After endoscopic mucosal resection, a clear diagnosis of adenomatous polyp in the colon was made, which is a lesion occurring in the intestine and requires prompt treatment. The patient was treated with surgical resection and anti-infection medication, and his condition is now under control and all indicators are improving.
Basic information】Male, 55 years old
Disease Type】Adenomatous polyp
Hospital】The First Affiliated Hospital of Kunming Medical University
Date of consultation】February 2022
Treatment plan】Surgical treatment (endoscopic mucosal resection) + medication (cefuroxime capsules, sodium chloride glucose injection, human albumin)
Treatment period】2 weeks of hospitalization and regular follow-up
Treatment effect] The disease has been controlled, and all indicators are improving
I. Initial consultation
The patient, a 55-year-old male, approached me who was working in the outpatient clinic with the laparoscopy report sheet. I carefully looked at the report sheet image data, which showed obvious abnormalities, and started to ask about the situation in detail. The patient reported: lower abdominal pain and abdominal distension 1 month ago, sudden weight loss, and weight loss of 3 kg in 1 month. Ultrasound examination at the local hospital showed the following findings: a large polypoid mass originating from the mesenteric border without transmural extension; the presence of several sub-centimeter enhancing peri-colonic lymph nodes; no mesenteric mass lesions, no iliac lymph node enlargement, etc. Subsequent examination revealed that the patient had a flat abdomen, soft abdomen, pressure pain and rebound pain in the left lower abdomen, and no abdominal mass; the liver was not palpable under the ribs, the spleen was not palpable under the ribs, and no abnormal bowel sounds were heard; routine blood and biochemical tests were not abnormal. The patient had no history of drug allergy, no abnormal family history, and a smoking history of more than 30 years. Preliminary diagnosis of colonic polyp was made, and the patient was admitted to the hospital.
II. Treatment history
After admission, the patient continued to improve blood glucose, lipids, liver and kidney function, C-reactive protein and other related tests, and the results were not significantly abnormal. Multiple polyps were seen in the sigmoid colon; tissue was taken for examination and pathology showed adenomatous polyps. After clinical examination and diagnosis, the diagnosis of adenomatous polyps in the rectosigmoid colon was confirmed, and symptomatic treatment was performed immediately. Endoscopic mucosal resection was performed to remove the polyp, and the specimen was sent to the laboratory for pathological examination, which clearly showed adenomatous polyp. The patient was monitored for vital signs and no abnormality. He was given water fasting, oral anti-infection treatment with cefuroxime capsules, intravenous rehydration treatment with sodium chloride glucose injection, and intravenous albumin supplementation with human albumin.
III. Treatment effect
After 2 weeks of hospitalization, the patient’s physical signs improved, complaining of relief of abdominal pain and bloating, and no other irritating reactions. After correct assessment of physical condition, the patient was discharged at the request of himself and his family. After a series of outpatient examinations and colonoscopy, the results showed that the patient’s prognosis was good, but he still needed to be reviewed regularly and to follow the doctor’s instructions to take medication on time to prevent recurrence and other complications. The patient and her family were satisfied with this treatment.
IV. Precautions
We are glad that the patient gradually recovered from the disease, but we need to advise the patient that he should pay attention to adjust his eating habits, advocate eating less and more, avoid overeating, eat mainly easy-to-digest, less dregs food, and keep the bowel movement smooth. When the body gradually recovers, pay attention to proper exercise to enhance immunity; maintain sufficient sleep, avoid overwork, pay attention to increase and decrease clothing according to the weather conditions to avoid catching a cold; also pay attention to maintain a relaxed and happy mood, communicate more with people, and establish a regular routine.
V. Personal insight
There are many glands in the mucosa of the gastrointestinal tract, and if the glands are hyperplastic due to inflammation or other stimuli, a polyp-like bulge will be formed. It is usually determined to be an adenomatous polyp by sending it to pathology testing after microscopic initialization. Unlike common inflammatory polyps, adenomatous polyps have the potential to become cancerous, so if a patient appears to be maladaptive, he or she should seek immediate medical attention for early detection, diagnosis, and removal. For the patient in this case, timely consultation is the key to buy some time for her postoperative recovery. After active treatment, following the medical advice to standardize the medication and regular review can help prevent the recurrence of the disease. At the same time, we also need to understand adenomatous polyps correctly and learn about adenomatous polyps, so that we will also recognize the importance of prevention and timely treatment.