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Abstract: The patient, 56 years old. He presented to our clinic with symptoms of abdominal pain, diarrhea, blood in the stool, and fever. He was diagnosed with intestinal polyps through physical examination combined with colonoscopy. Due to the small size of polyps, high-frequency electrical excision of polyps was performed during colonoscopy, and all polyps were removed. 3 months later, he was rechecked and found to have fully recovered from the disease without recurrence of polyps.
Basic information】Female, 56 years old
Disease Type】Intestinal polyp
Hospital】The First Hospital of China Medical University
Date of consultation】March 2022
Treatment plan】Surgery (endoscopic polypectomy) + medication (Ceftriaxone sodium for injection)
Treatment period】5 days of inpatient treatment, review after 3 months
Treatment effect] Abdominal pain, diarrhea, blood in stool, and fever disappeared, and no recurrence occurred.
I. Initial interview
The patient is a 56-year-old female. She reported that she had frequent abdominal pain and diarrhea in the last half month. She thought it was caused by unhygienic food and did not pay much attention to it, and her symptoms improved after changing her diet. However, in the past two days, he suddenly developed bloody stools and fever, so he was worried if there was a more serious disease in his body. I found that the patient’s abdomen was soft, without pressure pain and rebound pain, but there were intestinal sounds, combined with the clinical symptoms described by the patient, the initial diagnosis of intestinal polyps, hospitalized, and the next step of examination to clarify the diagnosis.
II. Treatment history
The patient was admitted to the hospital with preoperative examinations such as routine blood and electrocardiogram, and it was clear that there was no contraindication to surgery. Then colonoscopy was performed, and flat polyps of 0.3×0.3 cm were found in the ascending colon and transverse colon respectively, with a total of 3 polyps. After obtaining consent from the patient, endoscopic polypectomy with high-frequency electrodes was performed to remove the polyps completely and electrocoagulation was performed to stop the bleeding. The procedure was relatively successful, and postoperative ceftriaxone sodium was administered intravenously to prevent infection. After 5 days of hospitalization, he recovered well and his condition was stable enough to be discharged home for recuperation, and he was instructed to come to the hospital for review in 3 months. After that, the colonoscopy should be repeated once a year to prevent the recurrence of intestinal polyps.
III. Treatment effect
Five days after the endoscopic polypectomy, the patient complained that the abdominal pain, diarrhea, blood in the stool and fever had disappeared, and although the intestinal wound had not fully recovered, the condition was more stable and he could be discharged home to continue recuperation. The patient’s condition was cured because the site of resection was healing well.
IV. Precautions
I was happy for the patient when I learned that she could be discharged after the symptoms of abdominal pain, diarrhea and blood in stool disappeared. However, the patient should not relax her vigilance after going home, and she still needs to strengthen her life care. In terms of diet, avoid spicy and irritating foods as much as possible, and focus on light and easily digestible foods to avoid harming the intestines that have not yet fully recovered. In addition, it is also necessary to pay attention to more rest and avoid strenuous exercise or overexertion. At the same time, since intestinal polyps have the possibility of recurrence, patients need to pay attention to regular re-examination of the intestinal tract after discharge from the hospital to detect and treat the recurrence of intestinal polyps in a timely manner.
V. Personal insight
Intestinal polyps are mostly due to chronic inflammation, genetic factors, in addition, bad habits, ageing can also induce the disease, the incidence of the disease in the middle-aged and elderly population is relatively high. Generally, when intestinal polyps are small, they can be completely removed directly during colonoscopy, as in the treatment of the patient in this case. However, if the polyps continue to grow in size or become malignant if left untreated, open surgery or even radiotherapy will be required. Therefore, it is recommended to seek medical attention as soon as there is a change in bowel habits or abdominal discomfort.