DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURES PERFORMED:
1. Esophagogastroduodenoscopy (EGD).
2. Gastric decompression.
PHYSICIAN: John Doe, MD
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman with well-known upper GI/gastroduodenal Crohn disease, who has had multiple surgeries and has had upper abdominal pain and vomiting. The patient had an EGD by Dr. Jane Doe six months ago, which was reportedly unremarkable in terms of any obstruction with her gastrojejunostomy; although, as usual, the patient was obstructed through her native pylorus.
The procedure, its risks, benefits, and alternatives were explained to the patient in the presence of the nurse, and the patient was consented to proceed. The patient had continuous pulse oximetry and intermittent blood pressure monitoring throughout the procedure.
PREMEDICATION: Fentanyl 75 mcg and Versed 4 mg.
DESCRIPTION OF PROCEDURE: After adequate premedication, the Olympus GIF-160 endoscope was inserted atraumatically into the esophagus and advanced under direct vision. The esophagus was normal in its entirety. The stomach was next sighted, and it was easily and symmetrically inflatable. The gastrojejunostomy was noted on the posterior wall of the fundus. The antrum and pylorus were deformed, and the duodenal bulb was its usual closed off self. Upon entering the gastrojejunostomy with the scope, a total of 400 mL was suctioned out of the afferent limb and stomach. The afferent limb was unremarkable, and the previously noted strictures and ulcerations had all been dilated and stayed dilated. Minimal ulceration was noted at the gastrojejunostomy itself, and inside the gastrojejunostomy with the two ends coming together, no significant stricture was noted. The endoscope was then withdrawn and the procedure terminated. The patient tolerated it well.
IMPRESSION:
1. Gastrojejunostomy anastomotic superficial ulceration.
2. Afferent limb syndrome with perforation still in the afferent limb, 400 mL was suctioned out of this.
RECOMMENDATIONS:
1. We are going to ask the patient to lean forward and to the left when she feels nauseous while she is vertical to try to empty the afferent limb.
2. We would like to avoid surgery if we could.
