Sample Report: Esophagogastroduodenoscopy
PREOPERATIVE DIAGNOSES
1. Foreign body of the esophagus.
2. Dysphagia
POSTOPERATIVE DIAGNOSES
1. Foreign body of the esophagus.
2. Dysphagia
3. Esophagitis and Schatzki ring of the distal esophagus with stricture.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy with random biopsies and esophageal dilatation.
DESCRIPTION OF PROCEDURE: After satisfactory IV analgesia with Versed and Sublimaze and topical anesthesia with viscous Xylocaine and Hurricaine spray, the procedure was performed without incident. The GIF video endoscope was inserted under direct vision. The patient was found to have a meat bolus in the distal esophagus. The patient was found to have a Schatzki ring and diffuse inflammation. The bolus was displaced into the stomach. The stomach itself had an inflamed gastric mucosa with linear streaking and superficial erosions in the antrum and prepyloric region. The first segment of the duodenum also had inflammation. The remainder was normal. The patient had no evidence of ulcerative, neoplastic, or polypoid lesions. I randomly biopsied the antral and prepyloric areas to exclude Helicobacter pylori and randomly biopsied the EG junction. I then did an esophageal dilatation using the balloon, without incident. I visualized the EG junction, and it seemed that the ring had been fractured, but I did not see any significant bleeding. The patient tolerated all of these procedures well and was returned to the recovery room in stable condition.