POSTPROCEDURE DIAGNOSES: (1) Duodenal ulcer. (2) Giant duodenal diverticulum. (3) Hiatal hernia and Schatzki ring.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy with biopsy.
ENDOSCOPIST: Michael Jones, M.D.
ASSISTANT: Jane Doe, L.P.N.
REFERRING PHYSICIAN: George Washington, M.D.
ANESTHESIA: Demerol 25 mg IV push, Versed 3 mg IV push.
INSTRUMENT USED: GIF-160 video chip endoscope.
EXTENT OF EXAMINATION: Second portion of the duodenum.
DESCRIPTION OF PROCEDURE AND FINDINGS: Informed consent was obtained. The video gastroscope was introduced into the esophagus, stomach, and duodenum with the following findings:
1. The vocal cords and larynx were normal.
2. The esophagus was completely normal, except for a Schatzki ring at the bottom part at 37 cm.
3. Between 37 and 40 cm, a small-sized hiatal hernia is noted. Retroflexed view shows no other abnormality other than this hiatal hernia.
4. Stomach is completely normal.
5. Duodenal bulb is impressive for ulcer with good depth. This is a 1-cm sized, clean-based, benign-appearing ulcer. Biopsies were taken from the antrum for Helicobacter pylori.
6. Second portion of the duodenum around the papilla shows a giant diverticulum which is very thin-walled. Internal organs could be seen through this thin wall.
DIAGNOSTIC IMPRESSION: The patient's symptoms are probably from the duodenal ulcer. This may have been contributed to by the aspirin.
PLAN:
1. Hold aspirin, if possible.
2. Prevacid 30 mg every day.
3. Return to see me in about 2-3 weeks.
4. If Helicobacter pylori is positive, she will require treatment.
Thank you, Dr. Washington, for the referral.
The scope is retroflexed or the maneuver is retroflexion - it is NEVER retroflex! :)PROCEDURE(S) PERFORMED: (1) Esophagoscopy. (2) Gastroscopy. (3) Duodenoscopy. (4) Colonoscopy.
ENDOSCOPIST: Kris Kringle, M.D.
ASSISTANT: Shirley Temple, R.N.
PREMEDICATIONS GIVEN: Sublimaze 62.5 mg IV, Versed 0.25 mg IV, ampicillin 2 grams IV, gentamicin 50 mg IV, because of history of valve replacement, Cetacaine spray.
INDICATIONS FOR THE PROCEDURE: This is an 84-year-old female with weight loss. She has been on aspirin. She has had heme-positive stool. Esophagogastroduodenoscopy is done to rule out gastric carcinoma and colonoscopy is done to rule out colonic lesion.
DESCRIPTION OF PROCEDURES: EGD: The esophagogastroduodenoscopy was performed under direct visualization using the Olympus GIF-140 video chip endoscope. The esophagus, stomach, pylorus, duodenal bulb, and the duodenum to the third portion were normal including on retroflexion, aside from a small hiatal hernia and some mild diffuse erythema, consistent with gastritis, but no ulcerations and no erosions. The scope was withdrawn.
COLONOSCOPY: Then in the left lateral position, the rectal examination revealed no mass. The PCF-140 video chip colonoscope was inserted through the anus and advanced through a moderately tortuous colon all the way to the cecum. The position was confirmed by identification of the ileocecal markings. There was scattered particulate stool obscuring small parts of the mucosa. There were small hemorrhoids on retroflexion but no other abnormalities. The endoscope was withdrawn. The patient tolerated the procedure well.
DIAGNOSTIC IMPRESSION:
1. Hiatal hernia.
2. Gastritis.
3. Hemorrhoids.
4. Heme-positive stool. The etiology of that is not clear. It could be from hemorrhoids, gastritis, or possibly small bowel source with weight loss. It is less likely, but always possible, because of inadequate prep and tortuosity, missed colonic lesion.
SUGGESTED PLAN:
1. Preparation-H p.r.n.
2. Small bowel series and if negative for malignancy, barium enema if the patient will allow that when she sees family physician for followup.
3. I discussed the above with the patient and the PCP. She will make an appointment to see him in two to three weeks.
POSTPROCEDURE DIAGNOSES: (1) Extensive diverticulosis throughout the colon. (2) Internal hemorrhoids - the cause of bleeding. (3) Ulceration of the sigmoid diverticulum. Differential diagnosis: Mild diverticulitis or aspirin-induced ulcer. (4) Multiple small rectal polyps.
PROCEDURE PERFORMED: Colonoscopy with snare polypectomy.
ENDOSCOPIST: Michael Jones, M.D.
ASSISTANT: Jane Doe, L.P.N.
REFERRING PHYSICIAN: George Washington, M.D.
ANESTHESIA: Demerol 25 mg IV push, Versed 2 mg IV push.
INSTRUMENT USED: PCF-AL160.
EXTENT OF EXAMINATION: Cecum.
QUALITY OF PREPARATION: Excellent.
DESCRIPTION OF THE PROCEDURE AND FINDINGS: Informed consent was obtained. Rectal examination by finger was unremarkable. The scope was introduced all the way up to the cecum without any difficulty. There was extensive diverticulosis throughout the colon.
The following findings were noted in a very well-prepped colon:
1. Cecum and ascending colon also showed some mild diverticulosis.
2. Transverse colon shows moderate diverticulosis.
3. Sigmoid and descending colon show extensive diverticulosis. A single diverticulum in the sigmoid colon is very large and has ulceration in the middle of it. This suggests the patient had acute diverticulitis, but more likely nonsteroidal-induced ulceration.
4. Rectum is unremarkable except for multiple small superficial polyps which are most likely hyperplastic. Also, internal hemorrhoids are noted.
DIAGNOSTIC IMPRESSION: The patient's rectal bleeding is probably coming from the internal hemorrhoids with the finding of polyps incidental.
PLAN: 1. Follow up polyp pathology. Most likely, this will be hyperplastic. If hyperplastic, the value of further colonoscopies in this 80-year-old lady in not so perfect health is limited.
2. In 5 years, we can review how she is and consider a colonoscopy and followup. I would favor the approach of not performing any further intervention at that time.
Thank you very much, Dr. Washington, for the referral.
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Thank you and May God Bless You,
Rosemarie
