HS317b - Coding & Classification of Health Data
Class Discussion
MRDx: carcinoma of bladder
Other: bowel obstruction, development of small bowel fistula
Procedures: 17/May – biopsy of pelvic mass
6/June – Left colostomy and curettage of abdominal fistula.
This is a 54 year old unfortunate man who presented to hospital with low back pain, of approximately two to three months duration which was constant, moderate in severity and there was no vertical radiation. He was also getting some leg cramps off and on and decreased appetite with weight loss of about twenty pounds over the last two months and mildly constipated.
His history revealed that this patient had a cystectomy and ileal conduit with a urethrectomy in September of 1988 following chemotherapy and a full course of radiation. His recovery from the surgery was uneventful but the pathology of this specimen revealed a poorly invasive transitional cell carcinoma of the bladder grade 3/3 with muscle invasion in almost all layers. He was subsequently followed up without any major complications.
On general physical examination this is a pale looking male, with a blood pressure of 100/60, pulse of 80 per minute, respirations 18 per minute and regular and he was afebrile. His head and neck was unremarkable. His chest was clear and had a good air entry. Abdomen was soft and non-tender, a well healed scar and the stoma was apparently normal. This patient has a palpable mass in the left lower abdomen just off the midline suprapubically which was hard and mobile. There was no regional abnormality associated and rectally there were multiple nodules on the right side of the rectum which was fixed. Mucosa was mobile and the rectum was somewhat stenosed.
This patient was admitted and underwent further evaluation by IVP, loopogram and also CT scan of the abdomen and chest which showed local metastatic disease and following that, on 17 May, transperineal biopsy of the pelvic wall was performed which was consistent with transitional cell carcinoma of the bladder metastatic.
Over a period of time this patient was getting worse from a pain point of view and he was started on MS-Contin. This patient developed cutaneous fistula communicating with the small bowel through the old incision. The patient developed symptoms of bowel obstruction and also radiologically there were some air fluid levels associated.
Dr. Freeman was consulted at that point and took the patient to the OR on June 6 and did a curettage of the abdominal fistula and left sigmoid colostomy. His postoperative recovery was uneventful and he had a good recovery. He was given an appointment with the Cancer Clinic for further follow-up. The necessary steps were taken and a prescription for MS-Contin was given at the time of discharge. The patient left the hospital in satisfactory condition.
Consultation note: Diagnosis: Stage C muscle invasive bladder cancer now with pelvic perineal recurrence.
This 54 year old man was admitted with a history of two months of lower back pain which is constant, moderate severity with no radiation. He had occasionally had leg cramps and he had lost twenty pounds over the last two months. In the past he has had urethrectomy, cystectomy, and ileal conduit in September of 1988 followed by chemotherapy MVAC and radiotherapy. The pathology of his tumour demonstrated poorly invasive transitional cell carcinoma Grade II out of III with muscle invasion through all layers. Rectal examination on admission demonstrated a hard multiple mass on the right side of the rectum fixed and which was felt to represent a residual/recurrent tumour. Workup including a CT scan and bone scan suggest a locally recurrent disease only. Chest X-rays not reported in the notes. A perineal biopsy has been performed which confirms muscle invasive carcinoma.
Disposition: In view of the patient’s symptomatology and severe pain, I think it is worth offering him palliative radiotherapy. I will have to review his pervious treatment to plan on dose and fields. I will arrange one course of treatment prior to discharge.
OR: Needle biopsy of pelvic mass
Under general anesthesia, this man is prepped in the usual manner. There is a large hard mass just lateral to the pelvic wall, it may be involving some of the wall on the right side of the pelvis. This was verified to be a deeper mass lesion in the pelvic area on CT scanning.
Using a true cut needle biopsy we got three good cores of tissue of the pelvic wall with minimal problems and I think this should give us a tissue diagnosis. It certainly looks and cuts like carcinomatous tissue.
Path: pelvic mass, needle biopsy; transitional cell carcinoma.
OR: left iliac colostomy
An open incision was made and through this, we were able to elevate a loop of sigmoid colon. This was divided with a stapler. The distal end was oversewn and the proximal end brought out as a colostomy and a muscutaneous suture was carried out. Condition satisfactory
Path: tissue from enterocutaneous fistula showing foreign body giant cell inflammatory reaction with granulation tissue, no evidence of neoplasm.
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