indications  

AGE			Male		Female	ASA:

Procedure: The upper endoscope was passed with ease through the crycopharyngeal muscle under direct visualization to the second portion of the duodenum. The scope was withdrawn and the mucosa was carefully examined. The patient tolerated the procedure without any problems. Retroflexion was performed to evaluate the cardia and fundus.

   GI SERVICE

 

Esophagus:  Normal mucosa
esophagitis			biopsies
mild     moderate      severe			irregular esophageal lining
LA CLASS : A     B      C     D			irregular Z line
Z line       Normal Z-line			Barrett's metaplasia
irregular        highly suggestive of Barrett's metaplasia
Z line located  at:	cm from the incisors
EG junction located at:	cm from the incisors
diaphragmatic pinch at:	cm from the incisors
top of gastric fold (DP)	cm from the incisors
top of intestinal metaplasia (IM)	cm from the incisors
hiatus hernia			dilators
small  medium  large   no hiatal hernia			Savary	60    54     51    48   42   38    33
			TTS	51    54      57  60
				30 sec hold     1 minute hold
esophageal varices          no varices			No blood on the dilator or guidewire post
grade I      grade II     grade III     grade IV
			Balloon catheter ablators: (hallo 360)
			21Fr  22 Fr    25 Fr    28Fr
esophageal Masses
mid esophagus     distal esophageal mass			Esophageal Z -stent with Dua valve
			54 F 14 cm
Schatzki's ring present      no Schatzki's ring present
foreign body in the esophagus
Candida esophagitis
proximal esophageal stricture			Other findings : (type)
Stomach (fundus,body,cardia)Normal mucosa			Stomach (antrum)Normal mucosa
Cardia	no tumors, masses or varices		antral ulcer
	ulceration		white base       stigmata of recent bleeding
			ulcer with smooth regular border and regular margins
			ulcer with irregular nodular border and margin
fundus	normal mucosa
	atrophic gastritis
	gastric varices
			Gastritis
body	no evidence of gastritis		diffuse gastric erythema
	prominent gastric folds
			white based erosions with focal erythema
	atrophic gastritis
	diffuse gastritis
Angularis	ulcer		erosions (antrum)
	gastritis
			focal pinpoint hyperemia
Postsurgical changes:
B II changes
B II changes with Roux-en-Y
B I  changes
			focal areas of intramucosal hemorrhages
			portal gastropathy
Clo test was performed
Multiple biopsies were taken			AVM
			non bleeding single AVM
			multiple antal AVM's
Pyloric channel  normal			Duodenum  (bulb) normal
Swelling at the channel with no actual ulcer noted			marked narrowing
Ulcer with irregular margins demonstrated			marked edema of bulb
Pyloric channel ulcer with no stigmata of recent bleeding			single ulcer with white base
pyloric channel ulcer with stigmata of recent bleeding			multiple duodenal ulcers
Multiple biopsies were taken of ulcer margin
2nd portion of duodenum normal			Therapeutic and Special techniques used
duodenitis			Snare cautery polypectomy
ulcer noted			ARGON PLASMA COAGULATOR
multiple ulcers			20 Watts       40 Watts    60 Watts
			5 sec        10 sec       15 sec         20 sec
			Polyp fulguration
areas with smooth, shiny appearance with no discernable villous light reflex			Saline assisted polyp removal
multiple biopsies taken to r/o Celia Sprue			Mucosal tattooing
			10 French Gold probe was used to control bleeding with epi
			7 French Gold probe with injector
			NO SPECIAL PROCEDURES WERE USED
Hypopharynx normal vocal cords, cricoid cartilage and pyriform sinuses			Halo 360
swollen cricoid cartilage			Peg placement      Post peg tube instructions
swollen pyriform sinuses			Bravo Study
irregular vocal cords			EGD assisted capsular endoscopy placement
			Stretta procedure

Impression

 

Normal Study	esophagitis	esophageal Ulcer	Esophageal Varices	candida esophagitis
Barrett's Esoophagus	erosive esophagitis	Gastric Ulcer	Esophageal Variceal hemorrhage	esophageal web
Irregular Z line	hemorrhagic esophagitis	Duodenal Ulcer	Mallory-Weiss tear	esophageal diverticulum
SSBE	schatzki's ring	Antral  Ulcer	Deulafoy Lesion	Stretta procedure
LSBE	duodenitis	gastritis	Gastric varices	Enteryx

 

hiatus hernia (S)	antral erosions	Lesser Curvature ulcer	Peg tube placement	BI changes
hiatus hernia (m)	hemorrhagic gastritis	Greater curvature ulcer	Bravo	BII changes
hiatus hernia (L)	multiple gastric erosions	Multiple gastric ulcers	Halo 360	friable gastr-duodenal
Esophagitis : LA CLASS	A  B   C    D	Esophageal Impaction

\-

Recommendations

 

F/U Dr. Monte	F/U Dr. Gaziano	F/U Concha	F/U Dr. Powers	F/U Dr. Strom
F/U Referring attending	F/U MCGlone	F/U Dr. Schmelzel	F/w MD	F/U Urology

 

F/U  Appointment in :		days	Weeks	months
Will follow as inpatient		years	prn	get lost

 

Educational material provided at discharge	no complications with procedure	Electronic Signature provided
multiple images were taken

Pathology Specimens

 

No path specimens were taken	tissue was retrieved	tissue taken but  not retrieved
	specimens in jar A	specimens in jar B

 

CLO test was performed during this session	CLO test was not performed	small bowel bx were performed during this session

Therapeutic Recommendation :

 

PPI therapy (start)	Stop all NSAIDS	check coulter q 24 hrs	Continue to hydrate	CPM
PPI high dose	Hold ASA	coulters q 12 hours	Maintain Hb of 10 mg /dl	resuscitate patient
PPI one dose per day (continue)	hold ASA , Plavix	coulters q8 hours	Reduce IV fluid rate
PPI therapy IV	hold ASA, Plavix and warfarin	coulters q6 hours	Control heaving
Omeprazole 40 mg	Prevacid 30 mg qday	Protonix 40 mg qday	Rabeprazole (Aciphex) 20	Zegrid
Nexium 40 mg	Prevpac	Helidac	Carafate 1 gm qid	Tylenol #3 elixer
GI cocktail