DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Irritable bowel and family history of colon cancer.
POSTOPERATIVE DIAGNOSIS: Normal colonoscopy.
PROCEDURE PERFORMED: Colonoscopy.
ENDOSCOPIST: John Doe, MD
ASSISTANT: Jane Doe, MD
INSTRUMENT USED: Olympus colonoscope.
ANESTHESIA: MAC, Versed 7 mg and fentanyl 45 mcg.
EXTENT OF EXAM: To the cecum.
PREPARATION: Fair.
LIMITATIONS: None.
INDICATIONS FOR EXAMINATION: The patient is a (XX)-year-old female with family history of colon cancer in addition to having complaints of irritable bowel-type disease.
PROCEDURE IN DETAIL: A physical examination was performed. The major risks and benefits associated with the procedure were explained to the patient in detail. The patient verbalized understanding and agreement with the same. The patient was connected to the appropriate monitoring devices and an IV was started. Continuous oxygen was provided via nasal cannula and intravenous sedation was administered in divided doses throughout the procedure.
After adequate sedation was achieved, the patient was placed in the left lateral decubitus position and a digital rectal exam was performed. This examination was within normal limits. A well-lubricated colonoscope was then inserted into the rectum and advanced under direct visualization to the level of the cecum. The cecum was identified by both visual and anatomic landmarks. A photograph was taken of the cecal cap, as well as the intussuscepting ileum. The scope was then fully withdrawn while examining the color, texture, anatomy and integrity of the mucosa from the cecum to the anal canal. The findings were consistent with normal colonic mucosa. The scope was completely retrieved upon exiting the anal canal and the procedure was terminated. The patient was then transferred to the recovery room in stable condition.
ENDOSCOPIC DIAGNOSIS: Normal colonoscopy.
RECOMMENDATIONS: Follow up in the clinic in 5 years.
Sample Report #2
PROCEDURE PERFORMED: Total colonoscopy with snare polypectomy, hot biopsy polypectomy, cold biopsy polypectomy.
DETAILS OF PROCEDURE: The patient was placed in the left lateral decubitus position, had the above IV sedation. He has a tortuous colon. The Olympus pediatric PCF-180 colonoscope was inserted and directed forward. It did have some stool residual, which had to be aspirated throughout the colon. There was a torturous sigmoid colon, but with slow insertion, we were able to get through that area, and with moderate pressure, we got to the right hemicolectomy anastomotic site and we identified small bowel. Right next to the anastomosis was a diverticuli. As we withdrew the scope in the distal transverse, there were two 6 mm sessile polyps, removed by cold biopsy forceps. No other lesions were seen aside from sigmoid diverticuli, which were moderate in amount, and at 20 cm was an 8 mm sessile polyp, approached by a small snare and snared and removed with 20 watt coagulation current and recovered. In the rectum was a 6 mm sessile polyp removed by hot biopsy forceps. There were minor internal hemorrhoids prior to withdrawal. Rectal examination was grossly normal.
Sample Report #3
REFERRING PHYSICIAN: John Doe, MD
PROCEDURE PERFORMED: Esophagogastroduodenoscopy.
MEDICATIONS: Fentanyl 50 mcg, Versed 4 mg.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was then placed in the left lateral decubitus position. IV sedation was started in a sequential fashion until the appropriate level of consciousness was achieved. Hurricaine spray was applied to the back of the throat and the endoscope was then advanced under direct visualization over the tongue, the esophagus, stomach and duodenum. It was slowly withdrawn and the mucosa was carefully evaluated. Duodenal mucosal abnormalities were not visualized. Antegrade and retrograde views of the stomach did demonstrate some mild nonerosive gastritis, predominantly in the antrum. Portal gastropathy was noted throughout the gastric body, cardia and fundus. Thickened gastric folds were noted and biopsied. Retroflexed view as well demonstrated no signs of a gastric varix, no coffee grounds or red blood were seen in the gastric lumen either. The scope was then withdrawn through the GE junction and careful examination did demonstrate shallow esophageal ulceration distally; biopsies were obtained. The suspicion of Barrett’s esophagus noted with two salmon tongues of mucosa emanating 1 cm proximal to the GE junction. Careful examination of the remainder of the esophagus did demonstrate a hyperemic esophagus without further ulceration. The scope was then withdrawn from the patient and the procedure terminated. It was well tolerated and there were no immediate complications.
POST-PROCEDURE DIAGNOSES:
1. Probable Barrett’s esophagus.
2. Distal esophageal ulceration.
3. Thickened hypertrophied gastric folds.
4. Portal gastropathy and nonerosive gastritis.
IMPRESSION AND PLAN: I suspect this patient’s upper GI bleed is likely related to the ulcerations noted on this examination. As we await results of biopsies, I will change his proton pump inhibitor from an IV drip to oral and begin oral feeding as well. Hemoglobin and hematocrit will continue to be followed and, if stable, discharge may take place tomorrow. Outpatient followup should be with Dr. Doe.
Sample Report #4
PROCEDURES PERFORMED: Esophagogastroduodenoscopy with biopsies and colonoscopy.
ESOPHAGOGASTRODUODENOSCOPY
PROCEDURE IN DETAIL: The patient was given topical benzocaine spray and placed on the left lateral decubitus position. Following the administration of appropriate anesthesia, a diagnostic gastroscope was advanced under direct vision to the second portion of the duodenum without difficulty. The Z-line was regular and noted at approximately 38 cm from the incisors. Examination of the esophagus otherwise was endoscopically unremarkable. Patchy erythematous gastropathy was visualized, particularly in the distal portion of the stomach. No ulcers however were visualized. The stomach appeared to distend normally. Retroflexed views in the stomach did not reveal additional abnormalities. Multiple biopsies were obtained secondary to the findings above. Examination of the duodenum was endoscopically unremarkable though, secondary to the patient’s history, biopsies were obtained for histology. No additional findings were noted as the scope was slowly withdrawn.
IMPRESSION: Erythematous gastropathy.
RECOMMENDATIONS:
1. Await pathology results.
2. Proceed with colonoscopy.
COLONOSCOPY
PROCEDURE IN DETAIL: The patient was repositioned and a digital rectal exam was performed. No significant colonic masses or lesions were palpated. A variable stiffness adult colonoscope was then advanced under direct vision to the cecum without difficulty. The patient did require left lower quadrant pressure for deep cecal intubation. The patient’s colon preparation was good. Clear identification of the appendiceal orifice as well as the IC valve. Careful examination of the colonic mucosa was then performed as the scope was slowly withdrawn. The examined cecum, ascending, transverse, descending, and sigmoid colon were otherwise endoscopically unremarkable. Retroflexed views in the rectum revealed nonbleeding internal hemorrhoids.
IMPRESSION: Hemorrhoids, otherwise unremarkable colonoscopy. The patient’s episode of bleeding may be secondary to the hemorrhoids. No evidence of rectal cancer or colon cancer recurrence was identified.
RECOMMENDATIONS: Repeat examination in three years or sooner if symptoms dictate.
Sample Report #5
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURES PERFORMED:
1. Colonoscopy with biopsy.
2. Esophagogastroduodenoscopy with biopsy.
ENDOSCOPIST: John Doe, MD
CONSENT: The risks, benefits, and alternatives were discussed and informed consent was obtained. Initially, the intent was to perform colonoscopy. After history of vomiting and upper gastrointestinal tract complaint was obtained, it was presented to the patient that upper endoscopy might be best performed during the same visit. The benefits and risks of this were given to the patient, and she agreed to proceed.
MEDICATIONS: Fentanyl 75 mcg IV, Versed 8 mg IV.
DESCRIPTION OF PROCEDURE: Inspection showed no abnormality in the perianal area. Digital rectal examination was normal. An Olympus pediatric adjustable colonoscope was inserted and advanced to the cecum. The quality of the bowel preparation was acceptable. Some fecal matter remained and a sample was collected and sent for study. The cecum was normal. Ileocecal valve was normal. Terminal ileum was normal. No lesions were seen in the ascending colon, transverse colon or descending colon. Diverticulosis was noted in the sigmoid. Also noted was a small polyp, which was removed with forceps. Internal hemorrhoids were noted. During the procedure, random biopsies were obtained from various locations along right, transverse and left colon to see if an explanation could be found for the patient’s unexplained diarrhea on a microscopic basis.
Upper endoscopy was preformed. The esophagus was normal. At the gastroesophageal junction, a polypoid lesion, quite friable and oozing slightly was noted. No lesions were seen in the stomach. Some hyperemia was noted in the antrum. Biopsy was obtained to test for Helicobacter pylori infection. Duodenal bulb and descending duodenum were normal. The lesion at gastroesophageal junction was not biopsied because of friability and fear of large vessel within.
The patient tolerated the procedure well, and there were no apparent complications.
Sample Report #6
OPERATION PERFORMED: Esophagogastroduodenoscopy with cold forceps biopsy.
DESCRIPTION OF PROCEDURE: The patient was placed in the left lateral decubitus position and sedated as outlined above. The video endoscope was inserted through the mouth and advanced to the descending portion of the duodenum under direct visualization without any difficulty. Duodenoscopy revealed a normal-appearing postbulbar duodenum as well as duodenal bulb. The scope was then withdrawn to the stomach. Gastroscopy revealed a normal-appearing antrum and distal gastric body mucosa. Retroflexion views revealed a normal-appearing angularis, a large hiatal hernia was noted. The scope was then withdrawn to the proximal gastric body. The diaphragmatic hiatus was at approximately 40 cm, and the gastroesophageal junction was at approximately 30 cm, making the hiatal hernia approximately 10 cm in size. In the distal portion of the hiatal hernia sac, there were a few Cameron lesions and some superficial erosions but no active bleeding was noted. The scope was then withdrawn through the esophagus. The esophageal mucosa just revealed an extremely tortuous esophagus, but this is expected with a large hiatal hernia. This may also be secondary to some degree of presbyesophagus. The visualized mucosa in the esophagus did appear grossly normal. The air was then removed from the patient’s stomach. The scope was then withdrawn. The patient tolerated the procedure well and there were no apparent complications noted.
Sample Report #7
PROCEDURES PERFORMED:
1. Colonoscopy with snare polypectomy.
2. Colonoscopy with biopsy.
3. EGD with biopsy.
INDICATIONS: Hemoccult positive anemia.
CONSENT: Informed consent was obtained after discussing the risks and benefits of the procedure including bleeding, infection, perforation, anesthesia reaction, as well as alternatives.
POSTOPERATIVE DIAGNOSES:
1. Colonoscopy to the cecum with excellent prep.
2. Left-sided diverticulosis.
3. A total of 3 polyps in the rectosigmoid region all measuring between 4 and 8 mm removed with hot snare recovered for histopathology.
4. Large spreading multinodular carpet-like polyp versus mass at hepatic flexure, multiple biopsies obtained. This will require surgical resection.
5. Normal esophagus.
6. Moderately active gastroduodenitis. Antral biopsies taken for CLOtest, rule out Helicobacter pylori.
DESCRIPTION OF PROCEDURE: The patient was placed in the left lateral position and sedated with fentanyl 50 mcg IV and Versed 3 mg IV. The Olympus 180 pediatric colonoscope was introduced into the rectum and advanced to the cecum without difficulty. The prep was excellent. The mucosa from the rectum to the cecum appeared normal without inflammation or colitis. There were numerous diverticula in the left colon. A total of 3 polyps were found in the rectosigmoid region measuring between 4 and 8 mm, all had fairly narrow-based attachment and each was removed with a hot snare and recovered for histopathology. There was an additional, quite large polyp at the hepatic flexure. This was superficial, spreading and carpet-like in nature, had multinodular characteristics and I would speculate that this could turn out to be at least a tubulovillous adenoma, if not already a more advanced polyp or neoplasm. This measured several centimeters in diameter and was semi-circumferential at this level. This was too big to endoscopically remove. Multiple biopsies were taken for histopathology. The remainder of the ascending colon and cecum were clear of polyps. The scope was withdrawn. Retroflexion in the rectum revealed moderate to large internal hemorrhoids, but no other findings. The scope was withdrawn and the patient turned around.
The Olympus video upper endoscope was introduced into the oropharynx and advanced to the second and third portion of the duodenum. The esophagus showed normal mucosa throughout without irritation or esophagitis. In the stomach, there was a moderately active congestive gastritis without focal erosions. Retroflexed view of the cardia, fundus and GE junction was unremarkable. In the duodenum, there was also a moderately active duodenitis with congestion with some submucosal hemorrhage, but no ulcer found. The distal duodenum was normal. The scope was withdrawn into the stomach where antral biopsies were taken for CLOtest to rule out H. pylori. The scope was withdrawn and the patient sent to recovery.
IMPRESSION: The colon polyps are most likely the source of the Hemoccult positive anemia. We await histopathology on both the polypectomies and the biopsies. It does appear that the lesion at the hepatic flexure is going to require surgical intervention no matter the histopathology, as this will be too large to safely endoscopically resect. Obviously, the patient’s other medical conditions will need to be stabilized prior to entertaining intervention for this lesion. I do believe that the polyps that are present may preclude anticoagulation at this point, as the patient has been recently diagnosed with atrial fibrillation. I am concerned about the possibility of oozing or bleeding if the patient were to receive heparin. With regard to the gastric duodenitis, we await CLOtest for H. pylori status. Will treat for eradication if positive. Will treat the patient with a proton pump inhibitor at this time.
Sample Report #8
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Esophagogastroduodenoscopy with esophageal variceal banding.
PHYSICIAN: John Doe, MD
INDICATION: Hematemesis in the setting of alcohol abuse in a patient with known history of esophageal varices.
POSTOPERATIVE FINDINGS:
1. Grade 2 to 3 distal esophageal varices between 36 and 40 cm with weal sign, status post successful deployment of 3 esophageal bands.
2. Portal gastropathy.
3. Gastroesophageal junction at 40 cm from the incisors.
MEDICATIONS: Versed 10 mg IV, fentanyl 75 mcg IV.
IMMEDIATE COMPLICATIONS: None.
PROCEDURE IN DETAIL: Informed consent was obtained. The patient was explained the risks and benefits of this procedure, including but not limited to, bleeding, infection, perforation, need for surgery and cardiopulmonary complications. The patient indicated his understanding of the above and signed the consent form. The patient was deemed to be ASA class II and therefore a candidate for conscious sedation. The patient was placed in the left lateral decubitus position. Mouthpiece was inserted and secured. After occurrence of conscious sedation, endoscope was introduced in the mouth and passed under direct visualization without difficulty to the fourth portion of the duodenum. Endoscope was then slowly withdrawn and mucosal circumference was inspected. Examination of the duodenal mucosa and entire examined portions was unremarkable.
Examination of the gastric mucosa revealed erythema of the antrum. There was increase in area of gastric and some mucosal hemorrhages in the body and fundus of the stomach. On retroflexion, there was no evidence of gastric varices. The GE junction was at 40 cm from the incisors. Between 36 and 40 cm from the incisors, there were varices distally in the esophagus that were grade 2 to 3 with a weal mark noticed. There was no active bleeding. The remainder of the esophageal examination was unremarkable. The endoscope was withdrawn and then the esophageal banding kit was done in the usual manner. The endoscope was then reintroduced in the mouth under direct visualization, advanced to the distal esophagus and 3 bands were successfully deployed. The patient tolerated the procedure well. There were no immediate complications.
RECOMMENDATIONS:
1. Start nadolol 40 mg daily, hold for systolic blood pressures less than 90.
2. Daily PPI treatment.
3. Stop alcohol.
