PROCEDURE TYPE: Esophagogastroduodenoscopy
Preoperative History
Patient is a 84 year old Black Male with decreased appetite, weight loss and dysphagia
Physical Examination
See recent note.
ASA: 3
Allergies: NKDA
Consent
The indications, alternatives and potential complications of
endoscopy were discussed with the patient and/or representative(s).
Potential complications of bleeding, perforation, infection and
complications of sedation were discussed. The need for surgery,
blood transfusion, hospital admission if a complication occurs was
explained to the patient. Informed consent was obtained from the
patient after providing the opportunity for questions.
Indications
Diagnostic: Dysphagia or odynophagia
Therapeutic: Botulinum Toxin therapy
Endoscopic Procedure Performed at GI Clinic
Esophagogastroduodenoscopy performed with Regular gastroscope to
second part of duodenum (depth of insertion 100 cm). Diet: NPO >
6 hours. Prep: None. Patient was in the left lateral position.
Findings
1) hypertonic Lower esophageal sphincter ; ( 38 cm from incisors.)
Pharmacologic dilation of the LES performed. 4 application(s)
of Botulinum toxin injected through the Sivak retractable
needle. Total ml: 8 .
2) Candidiasis of whole esophagus
Mucosal brushing perfomed using a retractable brush; sent for
microbiology examination
3) Single non bleeding Angiodysplastic lesion(s) of stomach body
4) Single ( 4 12 mm) pedunculated non ulcerated non bleeding Polyp(
s) of anterior wall and lesser curvature of stomach antrum
Biopsy obtained using regular forceps; sent for histologic
examination
The remainder of the examination to second part of duodenum was
normal.
Therapeutic Outcomes & Specimens
Complete dilation acomplished (finding #1). Specimen retrieved
for examination (finding #4, #2).
Endoscope cleaned with Metrozyme mechanical wash and Cidex
disinfectant soak.
Procedure Medications
2 mg Midazolam administered by IV.
Complications
Heart rate, blood pressure and O2 saturation monitored and stable.
No immediate complications.
Disposition & Recommendations
Discharged patient to home. Discharge instruction sheet was
discussed and given to patient. Recommendations: 1) Await
histopathology 2) Await brushings. Start Diflucan x10 days
3) Anti reflux measures 4) Continue Protonix
Diagnoses
Pedunculated Polyp(s) of stomach antrum (211.1)
Non Bleeding Angiodysplasia of stomach body (537.82)
Suspected Candida Esophagitis of whole esophagus (112.84)
Suspected Achalasia (530.0)
Comments
20 units (in 2 mL) of Botulinum Toxin injected x 4 quadrants at
the GE junction. See recommendations above.
Pathology Report
CLINICAL HISTORY
Not Given
OPERATIVE DIAGNOSES
Not Given
Operation/Specimen: Stomach, antrum, biopsy
PATHOLOGICAL DIAGNOSIS:
Stomach, antrum, biopsy: Consistent with hyperplastic polyp
***Electronically Signed Out***
Usha B. Raju, M.D., Senior Staff Pathologist
vg/10/14/2005
GROSS DESCRIPTION
Stomach, antrum, biopsy:
FIXATIVE: Formalin. NO. PIECES: 3. SIZE/VOL: 1-2 mm. CASSETTES: 1, NS.
cfs/10/13/2005
John Mair
ICD-9(s):
211.1 211.1