DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Esophagogastroduodenoscopy with biopsy.
INDICATIONS: This is a (XX)-year-old Hispanic male with prostate cancer, metastatic, to multiple bones, who has had persistent nausea and vomiting.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The procedure, its risks, benefits, and alternatives were discussed. The patient was placed in the left lateral decubitus position and given local anesthetic to the oropharynx. The patient was sedated with fentanyl 25 mcg and Versed 4 mg given by slow IV push in incremental doses. The Olympus GIF-160 video endoscope was inserted into the oropharynx and guided under direct vision into the esophagus, stomach, and duodenum. The duodenal bulb and second portion were unremarkable. The scope was withdrawn to the stomach and retroflexed. There was no increased fluid, food or secretions in the upper gastrointestinal tract. There was very minimal, nonspecific, patchy antral erythema. Biopsies were obtained for Helicobacter pylori. No erosions or ulcers. The scope was withdrawn to the esophagus. The Z-line and gastroesophageal junction were located at about 40 cm. No Barrett’s or esophagitis. The patient tolerated the procedure very well. The patient was then transferred to the recovery area in good condition. There were no apparent complications.
POSTOPERATIVE DIAGNOSIS: Essentially normal esophagogastroduodenoscopy.
RECOMMENDATIONS:
1. Could try Reglan 10 mg before meals.
2. Will schedule an ultrasound of the abdomen.
3. CT scan of the head has been scheduled for later today. Will also exclude a central cause of his nausea and vomiting.
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DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Esophagogastroduodenoscopy with biopsy.
INDICATIONS: Chronic reflux. Evaluate for complications of reflux.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The procedure, its risks, benefits, and alternatives were discussed. The patient was placed in the left lateral decubitus position and given local anesthetic to the oropharynx. The patient was sedated with fentanyl 75 mcg and Versed 7 mg given by slow IV push in incremental doses. The Olympus GIF-160 endoscope was inserted into the oropharynx and guided under direct vision into the esophagus, stomach and duodenum. The duodenal bulb and second portion were unremarkable. The scope was withdrawn in the stomach, retroflexed. There was noted to be a moderately large sliding hiatal hernia. No abnormalities in the stomach were noted. The scope was withdrawn to the esophagus. The lower edge of the hernia was at 46 cm and the proximal end at 40 cm from the incisors. The lower esophageal sphincter appeared lax. There was a linear streak that came up 1 cm more proximally with mild central inflammation, indicating that this probably represents reflux. Biopsies were obtained to evaluate and to rule out Barrett’s. The esophagus above appeared unremarkable. Grossly normal-appearing vocal cords were seen during withdrawal of the endoscope. The patient tolerated the procedure very well. The patient was then transferred to the recovery area in good condition. There were no apparent complications.
POSTOPERATIVE DIAGNOSIS: A 6 cm sliding hiatal hernia with lax lower esophageal sphincter and grade 1 esophagitis.
RECOMMENDATIONS:
1. Review biopsy.
2. Will discuss options for therapy.
