DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Peptic ulcer disease.
2. Gastroesophageal reflux disease.
3. Gastritis.
POSTOPERATIVE DIAGNOSES:
1. Normal-appearing esophagus, mild esophageal spasticity.
2. Normal gastroesophageal junction.
3. Mild gastritis.
4. Healed gastric antral ulcer.
5. Normal duodenum.
6. No evidence of active bleeding or severe gastritis currently.
7. Normal esophageal mucosa.
PROCEDURE PERFORMED:
1. Esophagogastroduodenoscopy (EGD) to third portion of the duodenum.
2. Biopsy of gastric antrum for pathologic determination of Helicobacter pylori.
ANESTHESIA: Demerol and Versed intravenous.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought into the endoscopy suite, placed on the table in left lateral decubitus, right side up, position. Blood pressure, pulse, saturation oxygenation and heart rate were monitored throughout the entire procedure. Nasal cannula oxygen was administered. The patient was heavily sedated using Demerol and Versed intravenously with excellent sedation. The patient’s hypopharynx was anesthetized with Cetacaine spray. A bite block was placed into her mouth.
After adequate sedation had been obtained, a gastroscope was placed into her hypopharynx and navigated through the cricopharyngeus. A slightly spastic cricopharyngeus was noted, but this was finally intubated without difficulty. Mild to moderate spasticity of the mid esophagus was noted, though normal mucosal lining was seen down to the GE junction. A sharp Z-line was noted without evidence of reflux esophagitis, Barrett’s changes, masses, ulcers or lesions. The gastroscope was sent in and no evidence of hiatal hernia. The stomach was entered and expanded symmetrically without evidence of linitis plastica or deformation. The lesser curvature was followed down to the pylorus where a mild gastritis was noted, but no ulcers, masses, or lesions to account for the patient’s symptomatology. An old healed prepyloric ulcer was noted and pictures were taken. Biopsies of the gastric antrum were obtained for pathologic determination for Helicobacter pylori. The pylorus expanded symmetrically and was intubated and normal duodenal bulb was seen. First, second and third portions of the duodenum were within normal limits.
The gastroscope was pulled back to the stomach, retroflexed and GE junction was visualized from within, revealing no evidence of hiatal hernia, masses, ulcers, lesions or varices. No evidence of active bleeding or symptomatology or clinical signs of pathology to account for the patient’s clinical symptomatology of epigastric abdominal pain. The gastroscope was placed back into neutral position and withdrawn. No active bleedings from the biopsies of the gastric antrum seen. The gastroscope was removed through a normal esophagus. The patient tolerated the procedure well.
IMPRESSION AND PLAN: Normal esophagus without evidence of reflux, mild gastritis, healed pyloric gastric ulcer and normal duodenum. The patient’s upper gastrointestinal findings would not account for her symptomatology and we still feel that her symptomatology is biliary in origin. Due to her borderline normal test in the asymptomatic state, she does not wish to have laparoscopic cholecystectomy unless her symptomatology worsens or radiologic confirmation of biliary dyskinesia can be obtained. The patient will be instructed to continue her antacid therapy as recommended and to follow in the office if her symptomatology recurs. At this time, no evidence of acute surgical pathology.
Thank you very much for allowing us to participate in this patient’s care.
