REFERRING PHYSICIAN: John Doe, MD
PROCEDURE PERFORMED: Esophagogastroduodenoscopy with esophageal variceal band ligation.
INDICATION: Hematemesis.
DESCRIPTION OF PROCEDURE: Informed consent was obtained and conscious sedation was achieved with Demerol and Versed. Total sedation used was 75 mg of Demerol and 7 mg of Versed. The patient tolerated the procedure well. The patient was placed in left lateral position and video EGD scope was introduced into the hypopharynx and advanced under direct vision up to the second portion of the duodenum without difficulty.
PROCEDURE FINDINGS:
1. The distal esophagus showed evidence of large esophageal varices with some of them having red wale sign indicating recent hemorrhage and also high risk for re-bleeding.
2. Stomach showed evidence of erosive gastritis, but no active bleeding.
3. The duodenum was normal.
The endoscope was withdrawn and a Saeed Six Shooter band ligation device was placed at the tip of the endoscope and the endoscope was reintroduced. Six bands were placed at different columns, specifically targeting the areas of red wale signs. The band ligation was successful. However, since there were significant varices, a total of ten bands were placed using another Saeed Six Shooter band ligation device.
DIAGNOSES:
1. Esophageal varices with signs of recent hemorrhage, high risk for re-bleeding.
2. Erosive gastritis.
RECOMMENDATIONS:
1. Continue proton pump inhibitors.
2. Start nadolol 40 mg a day.
3. See the patient in the office in about two weeks.
4. The patient will need a repeat upper endoscopy and band ligation in about three weeks.
Thank you, Dr. Doe, for the opportunity to participate in this patient’s care.
