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Endoscopy Lab Report

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REASON
PROCEDURE: Upper endoscopy.

INDICATION
Surveillance endoscopy. Patient with personal history of hemorrhagic duodenal ulcer during transit between New Jersey and North Carolina. Patient presented to outside hospital in Philadelphia, Pennsylvania, undergoing endoscopy 11/2017 with findings of hemorrhagic duodenal ulcer. Treatment includes application of hemoclip. Patient is status post PPI therapy. He is asymptomatic. No longer on PPI therapy. I am to document ulcer healing.

DESCRIPTION OF PROCEDURE
Time-out was called. Consent signed. IV sedation administered. The forward-viewing endoscope was passed into the esophagus, advanced into the second portion of the duodenum without difficulty. Upon withdrawal, the following findings were noted.

FINDINGS …show more content…
There is evidence of edema and focal erythema within the duodenal bulb. There is slight narrowing of the lumen but no obstruction. The second portion of the duodenum was normal.

Stomach: The antrum body, fundus, and cardia portion of stomach were normal. There was no gastritis or erythema. No ulcers were seen. Gastric folds were normal. No gastric varices. Sampling was obtained from the antrum, incisura, body, and fundus of the stomach to evaluate for the presence of Helicobacter pylori.

Esophagus: The squamocolumnar junction was irregular with one mucosal break noting a single gastric island of columnar mucosa at or near the EG junction. This area was biopsied to exclude short-segment Barrett's esophagus. Otherwise, no ulcerations were seen. There was no hiatal hernia and the more proximal esophageal body was normal. The procedure then was terminated.

ASSESSMENT
1. Healed duodenal ulcer with residual mild erythema.
2. Normal-appearing stomach status post biopsy rule out Helicobacter pylori.

3. Focal esophagitis rule out Barrett's esophagus.

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