DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Change in bowel habits.
2. Chronic diarrhea, bloating, belching, and abdominal pain.
POSTOPERATIVE DIAGNOSES:
1. Normal colonoscopy to the cecum.
2. Gastritis.
3. Mild distal esophagitis.
PROCEDURES PERFORMED:
1. Colonoscopy to the cecum, random cold biopsy of colon and rectum.
2. Esophagogastroduodenoscopy.
3. Cold biopsy of duodenum, rule out celiac sprue.
4. Cold biopsy of antrum and stomach for gastritis, rule out Helicobacter pylori.
5. Biopsy of the distal esophageal gastroesophageal junction, rule out Barrett esophagus.
SURGEON: John Doe, MD
ANESTHESIA: Demerol 75 mg, Versed 6 mg and propofol 150 mg.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATION FOR PROCEDURE: This is a (XX)-year-old gentleman who presented to the office complaining of change in bowel habits. The patient has had diarrhea for the last several months. The patient describes having several loose bowel movements per day. The patient also is complaining of having bloating, belching and abdominal pain. The patient is status post laparoscopic cholecystectomy 6 years ago. The patient states the symptoms occur after eating. The patient presents at this time for an upper and lower endoscopy. The procedure including risks, benefits and potential complications such as bleeding and perforation were discussed with the patient. The patient understood and gave informed consent.
PROCEDURE FINDINGS: The patient had a normal colonoscopy to the cecum. The ileocecal valve was unable to be intubated. It was well visualized but the scope could not be passed through the relatively tight ileocecal valve. There was evidence for moderate antral gastritis and gastritis in the remaining portion of the stomach. There was some distal esophagitis.
DESCRIPTION OF PROCEDURE: The patient was brought to the endoscopy suite and placed in the left lateral decubitus position. Appropriate monitors were applied. The patient was given IV sedation and anorectal examination was performed. The patient’s prostate was normal and the anorectal examination was unremarkable. The scope was placed into the rectum and advanced to cecum without difficulty. The patient’s cecum was easily entered. The ileocecal valve was well visualized but could not be intubated despite multiple attempts. The scope could not be passed through the ileocecal valve. At this point, the scope was brought back out. The patient had an excellent bowel prep. Cold biopsies were taken throughout from the cecum to the rectum. In the rectum, scope was retroflexed and no abnormalities were noted, except for some hemorrhoidal tissue. The scope was placed back in the lumen and the excess air was aspirated. The patient tolerated this portion of the procedure well.
Next, the upper endoscopy was performed after bite block was placed. The scope was passed through the oropharynx into the stomach. The stomach was insufflated and pylorus was identified. The scope was passed through the pylorus into the second portion of the duodenum. The duodenum was then examined. Cold biopsies were taken of the duodenum to rule out celiac sprue. The duodenum appeared normal as well as duodenum bulb. In the stomach, the patient had some gastritis, more so in the antrum. Biopsies were taken in several spots throughout the stomach to rule out H. pylori. The scope was retroflexed, but it was somewhat difficult to retroflex. The scope was placed back into the lumen. It was also noted the patient had some moderate amount of bile within the stomach. The scope was brought back out further at the GE junction. The patient had some distal esophagitis noted with some changes of the mucosa. Biopsies were taken to rule out Barrett esophagus. The scope was brought back out. The remaining portion of the esophagus appeared normal. The scope was placed back in the lumen and the stomach and the excess air aspirated. The procedure was then completed. The patient tolerated the procedure well without any complications.
The above findings were discussed with the patient. Recommend an upper GI small bowel follow-through to evaluate the stomach for its emptying and any abnormalities. In addition, ordered small bowel follow-through to fully evaluate the small intestines, especially terminal ileum. Also placed the patient on Prevacid. Await the biopsy results.
