DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Cryptogenic cirrhosis.
2. Portal hypertension with thrombocytopenia, rule out esophageal varices.
POSTOPERATIVE DIAGNOSES:
1. Early grade 1 out of 4 distal esophageal varices.
2. Moderate diffuse congestive gastropathy/gastritis with no evidence of gastric varicosities or ulcers.
3. Probable short segment Barrett esophagus.
PROCEDURE PERFORMED: EGD to second duodenum, diagnostic.
PROCEDURE FINDINGS:
1. Mildly tortuous esophageal body with the presence of two columns of early grade 1/4 distal esophageal varicosities extending down to the gastroesophageal mucosal junction Z-line at 38 cm, which appeared moderately irregular with 0.5 up to 1 cm proximally extending tongues of Barrett-type epithelium. No evidence of active endoscopic esophagitis, ulcerations or gross neoplastic changes. No biopsies were obtained due to the patient’s underlying thrombocytopenia in the setting of developing varicosities.
2. Moderately severe and diffuse gastric mucosal edema and erythema with diffuse submucosal petechial hemorrhaging and no evidence of gastric varicosities, ulcerations, mass lesions.
3. Patent pylorus with normal duodenum, including duodenal bulb and postbulbar duodenum to the second portion with no duodenitis, ulcerations or luminal narrowing.
MEDICATIONS: Fentanyl 250 mcg and Versed 15 mg, both slow IV push, titrated.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was placed on her left side. Her posterior oropharynx was sprayed with Cetacaine spray, and a bite block was placed. The patient was then sedated with IV fentanyl and Versed titrated. An Olympus video upper endoscope was introduced through the mouth and the posterior oropharynx, which was grossly inspected and appeared unremarkable. The proximal esophagus was intubated under direct visualization without difficulty. A small amount of air was insufflated to distend the lumen. The scope was then easily advanced distally down the esophagus, carefully inspecting the mucosa all the way down to the gastroesophageal mucosal junction Z-line which, as noted, was somewhat irregular at 38 cm with probable short segment Barrett tissue. There was no evidence of inflammatory changes, ulcerations or neoplastic changes. As noted, there were two columns of early developing varicosities within the distal esophagus. The scope was then introduced in the stomach, where pooled fundic secretions were aspirated out prior to insufflating a small amount of air to distend the lumen. The gastric mucosa was irrigated and lavaged on forward as well as retroflex views. The stomach was then inspected carefully on forward as well as retroflex views. The scope was then introduced through a patent pylorus and duodenum bulb and subsequently postbulbar duodenum, all of which were inspected and appeared normal. The scope was then drawn back in the stomach, which was reinspected confirming the findings of moderately severe diffuse mucosal edema and erythema with diffuse submucosal petechial hemorrhaging consistent with an inflammatory congestive process. No biopsies were taken due to the patient’s low platelet counts. The air as well as pooled secretions was then aspirated out of the stomach. The scope was drawn back up the esophagus, which was carefully reinspected while suctioning the patient on scope withdrawal. The patient tolerated the procedure well with no evidence of immediate complications. She was transferred to the recovery area in stable condition.
IMPRESSION:
1. Cryptogenic cirrhosis secondary to nonalcoholic steatohepatitis or possibly autoimmune disease with complications of portal hypertension, thrombocytopenia, and early developing distal esophageal varicosities.
2. Moderate diffuse congestive gastropathy and gastritis of the stomach, not biopsied due to the patient’s thrombocytopenia.
3. Probable short segment Barrett esophagus consistent with chronic gastroesophageal reflux disease.
RECOMMENDATIONS:
1. High-dose suppression therapy with proton pump inhibitor indefinitely along with reflux precautions.
2. Complete avoidance of aspirin and nonsteroidal anti-inflammatory agents.
3. Await liver biopsies to be performed through the transjugular route.
