292) A 66 year old man is evaluated in the emergency room for abdominal pain and fever. The patient underwent a screening colonoscopy in the outpatient Gastroenterology clinic 8 hours ago and had a 3cm sessile polyp removed. He complains of moderate pain in left lower quadrant that started one hour ago. He denies nausea or vomiting or rectal bleeding. On examination, temperature is 100.8F, blood pressure 140/90 mmHg, pulse 102, respiratory rate 20 bpm. Abdominal examination reveals tenderness and guarding in the left lower quadrant. There is no rigidity or rebound tenderness. His laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits. Which of the following is the most appropriate next step in managing this patient?
A) Exploratory Laporotomy
B) Rectal tube placement
C) Flexible sigmoidoscopy
D) CT Scan of the Abdomen
E) Conservative management
Filed under: Uncategorized, USMLE Test Prep | Tagged: ARCHER GASTROENTEROLOGY, archer surgery, post-polypectomy bleeding, post-polypectomy complications, post-polypectomy electrocoagulation syndrome, post-polypectomy perforation, USMLE STEP 3 GASTROENEROLOGY, usmle step 3 surgery |
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E
D
D
D – he’s too tachycardic for conservative management.
E
D
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Dr Red i think we need help with these ………..
Correct Answer. D Post-polypectomy electrocoagulation syndrome can occur in about 20% cases after polyp removal. It’s presentation can be confused with perforation after polypectomy. Perforation occurs only in 1% cases after polyp removal
Post-polypectomy electrocoagulation syndrome can present with left lower quadrant pain, tenderness and sometimes, rigidity. Fever can be present. This is secondary to inflammation at the site of electrocoagulation at polypectomy site. It is important to consider this common entity in order to avoid unnecessary interventions. Clinically, it may be difficult to differentiate it from early perforation. Hence, a CT scan must be first obtained to exclude free air in the abdomen in cases where perforation is suspected.
A is incorrect. If CT shows free air, then Choice A ( Surgery) is appropriate.
C incorrect. Flexible sigmoidoscopy to evaluate the polypectomy site is not indicated. The patient has no bleeding and this amy be dangerous if perforation is present at the site.
B is incorrect. Rectal tube placement is indicated in Oglivies syndrome not here.
E is incorrect. Conservative management ( Nothing by mouth, IV fluids, NSAIDs) is indicated once the diagnosis of Post-polypectomy electrocoagulation syndrome is confirmed.
D