Colonoscopy

Relevant evidence may include the procedure report, location of any biopsy or polypectomy, endoscopic findings, onset of abdominal symptoms, imaging, laboratory results, and subsequent surgical records. These materials may help establish when the perforation became clinically apparent, its possible location and mechanism, and whether signs of the injury were recognized during or after the procedure.

An incomplete colonoscopy generally means that the examination did not reach the intended endpoint, while an inadequate examination may occur when bowel preparation or visualization prevents sufficient inspection of part of the colon. The record may be used to identify whether the cecum was reached, how bowel preparation was documented, why the procedure was stopped if incomplete, which areas were adequately visualized, and what follow-up was recommended. The significance depends on the clinical indication and the portion of the colon that was not adequately examined.

The clinical course may be reconstructed using the size and location of the polyp, removal technique, use of cautery or other hemostatic measures, antiplatelet or anticoagulant medications, immediate bleeding, and the timing of later symptoms. Emergency treatment, laboratory findings, hospitalization records, or repeat colonoscopy may provide additional information about the severity and possible source of the bleeding.