PREOPERATIVE DIAGNOSES: 1. Incontinent diarrhea 2. Severe heartburn...

Question Answered step-by-step PREOPERATIVE DIAGNOSES: 1. Incontinent diarrhea 2. Severe heartburn… PREOPERATIVE DIAGNOSES: 1. Incontinent diarrhea 2. Severe heartburn POSTOPERATIVE DIAGNOSIS: Severe reflux esophagitis with hiatal hernia SURGEON: Mitchell P. Dorfsman, MDOPERATION: Esophagogastroduodenoscopy with multiple biopsies ANESTHESIA: 2 mg of Versed, 100 mcg of fentanyl, and 0.4 mg of atropine ESTIMATED BLOOD LOSS: Minimal INDICATIONS: A pleasant female who consulted for incontinent diarrhea but also discussed a severe amount of what appeared to be symptoms of reflux. Consequently, we discussed doing a colonoscopy as well as an EGD. The procedure, risks, benefits, and alternatives were discussed about doing an EGD. She understood and wished to proceed with the scope. FINDINGS: A severe amount of esophagitis noted, with creeping of squa- mocolumnar junction and erythema up along the lower esophagus. Also of note is a moderate hiatal hernia. PROCEDURE: The patient was brought into the ER endoscopy suite area. After informed consent was obtained, the patient gargled with Pontocaine solution and was given the medication as noted above. We then had the patient sit upright, placed the flexible scope into the oropharynx, and had her swallow it into her esophagus. We then had her lie in the left lateral decubitus position. Under direction vision, we passed the scope through the esophagus and into the stomach, through the pylorus and into the third portion of the duodenum. We then retracted the scope slowly, with no evidence of ulcers, abnormalities, or lesions noted within the duodenum. The pylorus also appeared to be unremarkable. The antrum, as well as the stomach, appeared to be unremarkable, with no evidence of erythema, which may have been secondary to the scope. Nonetheless, normal rugae folds were identified. Retroflex examination showed a moderate-sized hiatal hernia, which was erythematous as well. No evidence of polyps, lesions, or abnormalities were noted in the cardia portion of the stomach. We then changed the scope back to the antrum and directed the scope slowly with no evidence of abnormalities, lesions, or any other problems within the stomach except for what was mentioned above. We then got to the hiatal hernia with no evidence of ulcerations or lesions noted, except for mild erythema. We then continued to retract the scope to the squamocolumnar junction. At this time, we noted a severe amount of erythema creeping up along the lower esophagus. This was biopsied multiple times for pathology, as well as H. pylori, and a biopsy was taken from the antrum. After obtaining several biopsies, we went back into the stomach, aspirated the air, came back into the lower esophagus, and continued to retract the scope slowly. No evidence of abnormalities or lesions was noted throughout the rest of the esophagus, and the vocal cords moved well together bilaterally, with no evidence of erythema, polyps, or lesions. It should be noted that the biopsies of the lower esophagus were obtained at what appeared to be high levels of the squamocolumnar junction, still above the squamocolumnar junction, but at times not reflective of the actual total height of the erythema. We then retracted the scope as noted above. The patient tolerated the procedure well and remained in stable condition throughout the procedure. PLAN: Place the patient on Carafate and Prilosec, and she will be scoped from below next week. CPT Code:ICD-10-CM Codes: _____, _____ICD-9-CM Codes: _____, _____ Health Science Science Nursing MBC601 P1210329 Share QuestionEmailCopy link Comments (0)