DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Esophageal foreign body.
2. Hiatal hernia.
POSTOPERATIVE DIAGNOSES:
1. Esophageal meat impaction.
2. Hiatal hernia.
3. Ulcer at stricture.
PROCEDURE PERFORMED:
Esophagogastroscopy with foreign body removal.
ENDOSCOPIST: John Doe, MD
ANESTHESIA: Demerol 50 mg IV push in divided doses, Versed 4 mg IV push in divided doses, oxygen by nasal cannula.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male who experienced an esophageal meat impaction yesterday. He is now undergoing therapeutic endoscopy.
INSTRUMENT: Olympus GIF-160.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was turned in the left lateral decubitus position and sedated. The endoscope was passed through the bite block into the oropharynx and into the esophagus while the patient was encouraged to swallow. The scope was passed under direct visual guidance. Upon entering the esophagus, there was thick liquid material. This was aspirated. The scope was advanced distally. The top of the gastric folds were at 31 cm. The apparent lower esophageal sphincter was 33 cm. Beyond this was a large hiatal hernia. At the distal aspect of the hernia was an esophageal meat impaction. Adjacent to this impaction was a deep and broad ulceration. There was no active bleeding but blood was present on the meat impaction. The meat impaction was firmly in place and initially did not pass with pressure from the scope. The plan was to grasp it with a 5-pronged foreign body removal instrument, but this was not available. While looking for the Roth retrieval net, the foreign body passed spontaneously into the stomach. As noted above, there was a deep and broad ulceration at the site where the foreign body was impacted. This was approximately 18 mm x 15 mm. There was no active hemorrhage. The remainder of the hiatal hernia was unremarkable. The scope was passed into the stomach. The gastric mucosa was carefully evaluated with straight on and retroflex viewing. No additional abnormalities were identified. The scope was withdrawn after washing the remaining material from the esophagus into the stomach and aspirating the residue. The patient tolerated the procedure well.
COMPLICATIONS: None.
SPECIMENS: None.
RECOMMENDATIONS:
1. Start Protonix 40 mg b.i.d.
2. Carafate suspension 1 g p.o. q.i.d.
3. Clear liquid diet.
4. Monitor overnight.
5. Repeat upper endoscopy in 1 month.
