ProcedureUpper GI Endoscopy
IndicationsBarrett's high grade dysplasia with carcinoma in situ
Patient Profile: This is a 78 year old male with BE with HGD/IMC s/p EMR/RFA here for surveillance. Last surveillance 7/19 with CEIM. Refer to note in patient chart for documentation of history and physical. Patient's current medications were obtained, updated, and reviewed by me (G8427). Patient was screened for tobacco use (4004F).
Medicines: Monitored Anesthesia Care.
Complications: No immediate complications.
Pre Procedure H&P and Procedure Note: Patient identification using first and last name and date of birth, and the proposed procedure were verified by the physician and nursing staff. After reviewing and explaining the proposed procedure, the potential risks/side effects; the possible results of not undergoing the procedure and any potential complications or recovery problems and the reasons alternative methods of treatment and their risks and benefits with the patient, the patient agrees with the procedure and wishes to proceed. Informed consent was obtained.
Diagnostic and radiological tests results necessary for procedure are available.
Blood/blood products and any special equipment/implants/devices needed for the procedure were discussed and available.
Immediately prior to the procedure I reevaluated the patient and it is safe to proceed and the procedure time out was completed per policy.
The endoscope was introduced through the mouth and advanced to the second part of duodenum. Heart rate, respiratory rate, oxygen saturations, blood pressure, pulmonary ventilation adequacy and response were monitored during procedure and physical status was reassessed after the procedure. The patient tolerated the procedure well.
Estimated Blood Loss: Estimated blood loss was minimal
Findings: The esophagus and gastroesophageal junction were examined with white light and narrow band imaging (NBI) from a forward view and retroflexed position. Sequelae of prior Barrett's treatment were seen, including scarring. There was no visual evidence of Barrett's esophagus, ulceration, or nodularity. Mucosa was biopsied with a cold forceps for histology in 4 quadrants at intervals of 1 cm starting at 0.5 cm below the SCJ to 1.5 above the SCJ. A total of 3 specimen bottles were sent to pathology. Estimated blood loss was minimal.
A few diminutive sessile polyps were found in the gastric body. The remainder of the stomach was unremarkable.
The examined duodenum was unremarkable.
Post Procedure Diagnosis/Impression: -Evidence of prior EET of BE without evidence of recurrent/residual disease. Biopsied.
Recommendation: -Discharge patient to home.
-Await pathology results.
-Repeat upper endoscopy in 1 year for surveillance.
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