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Abstract: Colorectal polyps are a common type of intestinal polyps with lesions confined to the large intestine. In this case, the patient was deeply troubled by this disease. She came to our hospital for treatment because of diarrhea and blood in stool aggravated for 1 week, and the diagnosis of large intestinal polyp was clarified by comprehensive examination, colonoscopy and gastroscopy, and she was treated with endoscopic intestinal polyp resection, injectable ceftriaxone sodium, Puyuan and stomach capsule, rabeprazole sodium enteric solution tablet and mosapride citrate tablet.
Basic information】Female, 64 years old
Disease Type】Intestinal polyp (large intestinal polyp)
Hospital】The First Hospital of China Medical University
Date of consultation】March 2022
Treatment plan】Surgical treatment (endoscopic polypectomy) + intravenous infusion (ceftriaxone sodium for injection) + oral medication (Puyuan and stomach capsule, rabeprazole sodium enteric solution tablets, mosapride citrate tablets)
[Treatment period] Hospitalization for 4 days, review after 1 month
Treatment effect】The condition has recovered well, abdominal pain and distension have disappeared
I. Initial consultation
The patient came to our hospital for treatment of diarrhea and blood in the stool, which had been aggravated for 1 week. Physical examination: body temperature 36.3℃, blood pressure 115/65mmHg, heart rhythm 84 beats/min; coarse breath sounds in both lungs, no dry rales; soft abdomen, but epigastric pressure pain, intestinal sounds. The patient had a history of chronic gastritis, thyroid nodule surgery, and hyperlipidemia, and was prone to abdominal distension, sometimes abdominal pain, but it was mild, and constipation. Colonoscopy showed two flat polyps of 0.4×0.4 cm in size in the rectum; gastroscopy showed chronic gastritis with erosion. Combined with the clinical manifestations of the patient’s preliminary diagnosis of intestinal polyps (colorectal polyps), admitted to the hospital for treatment.
Second, the treatment process
I told the patient that the large intestinal polyp was relatively less serious and suggested direct hospitalization for endoscopic intestinal polypectomy. The patient and his family agreed to this treatment plan, and after good preoperative preparation, endoscopic polypectomy was performed under general anesthesia, and the polyps were removed from the body after complete ligation, and ceftriaxone sodium for injection was administered intravenously after the operation to prevent infection. 4 days later, the surgical wound recovered well and the condition was stable, so the patient was discharged from the hospital, but a review was needed after 1 month. After the operation, the patient was advised to take Pu Yuan He Gastric Capsules, Rabeprazole Sodium Enteric Tablets and Mosapride Citrate Tablets for 4 weeks for chronic gastritis.
III. Treatment effect
The patient presented with diarrhea and blood in stool before treatment, and was admitted to the hospital after endoscopic intestinal polypectomy, and the large intestinal polyp was completely removed. Gastroscopy showed that the erosion of gastric mucosa was healed.
IV. Precautions
I was happy that the patient could be discharged after her condition was stabilized. However, since the intestinal wound had not yet healed completely, the patient should be instructed to take more rest and avoid strenuous exercise or overexertion after going home, so as not to cause the intestinal wound to open and affect the intestinal recovery. In terms of diet, it is also necessary to pay attention to a diet with less residue for 2 weeks to avoid food irritation of the gastrointestinal tract, and gradually resume a normal diet after 2 weeks. For oral medication, you need to adhere to the medical advice and avoid adding or subtracting medication without authorization to avoid affecting the efficacy of the medication and causing adverse consequences to the body. If there are changes in the condition such as worsening of symptoms, it is necessary to follow up the treatment in time.
V. Personal insight
The clinical symptoms of patients with colorectal polyps are not obvious, and only when the polyps are large will there be constipation, diarrhea, blood in the stool, abdominal distension, abdominal cramps and other manifestations. Therefore, it is recommended that middle-aged and elderly people should pay attention to their own situation and seek medical treatment without delay when symptoms appear.