Esophagogastroduodenoscopy (EGD) / Upper Endoscopy
[Dysphagia / Gastroesophageal reflux disease / Epigastric pain / Iron deficiency anemia / Barrett's esophagus surveillance / Upper gastrointestinal bleeding]
Same
Esophagogastroduodenoscopy [with biopsy / without biopsy]
[***, MD/DO]
[Resident/PA name]
[Monitored anesthesia care / Moderate sedation / General endotracheal]
The patient is a [age]-year-old [male / female] with [indication] referred for upper endoscopy. The risks, including bleeding, perforation, aspiration, and sedation-related complications, as well as the benefits and alternatives, were discussed, and informed consent was obtained.
Esophagus: [normal / ***]. The Z-line was [regular / irregular] at [X] cm from the incisors. [No hiatal hernia was seen / A [X]-cm hiatal hernia was present].
Stomach: [normal / ***]. The retroflexed view of the cardia and fundus was [normal / ***].
Duodenum: The bulb and second portion were [normal / ***].
A time-out was completed confirming the patient, procedure, and allergies. The patient was placed in the left lateral decubitus position, sedation was administered, and a bite block was placed.
The gastroscope was introduced into the oropharynx and passed into the esophagus under direct vision. It was advanced through the stomach and pylorus into the second portion of the duodenum. The duodenum, pylorus, antrum, and gastric body were examined with adequate insufflation. The endoscope was retroflexed in the stomach to examine the cardia, fundus, and gastroesophageal junction, then straightened. The esophagus was examined during withdrawal, and the location of the Z-line was recorded.
[Cold forceps biopsies were obtained from the [gastric antrum and body / duodenum / distal esophagus / ***] and sent to pathology in labeled containers.]
Photographs of the landmarks and findings were obtained. Air was suctioned from the stomach, and the endoscope was withdrawn.
None
[Biopsies to pathology as described / None]
Minimal
None
The patient tolerated the procedure well and was taken to the recovery area in stable condition. Pathology results will be followed up and reviewed with the patient.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Esophagogastroduodenoscopy [with biopsy / without biopsy]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [Monitored anesthesia care / Moderate sedation / General endotracheal]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** referred for upper endoscopy. Risks, including bleeding, perforation, aspiration, and sedation-related complications, benefits, and alternatives were discussed, and informed consent was obtained.
FINDINGS:
Esophagus: ***. Z-line [regular / irregular] at *** cm from the incisors. [No hiatal hernia / *** cm hiatal hernia].
Stomach: ***. Retroflexed view of the cardia and fundus: ***.
Duodenum: Bulb and second portion ***.
DESCRIPTION OF PROCEDURE:
Time-out completed. Left lateral decubitus. Sedation administered and bite block placed. The gastroscope was passed into the esophagus under direct vision and advanced through the stomach and pylorus to the second portion of the duodenum. The duodenum, pylorus, antrum, and body were examined with insufflation. Retroflexion was performed to examine the cardia, fundus, and GE junction. The esophagus was examined on withdrawal and the Z-line recorded. [Cold forceps biopsies were obtained from *** and sent to pathology.] Photographs obtained. Air was suctioned and the endoscope withdrawn.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Biopsies as described / None]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to recovery in stable condition. Pathology will be followed up.
Signed: .ME, .MYDEGREE
.TODAYVariants
Barrett's Esophagus Surveillance Biopsies
Salmon-colored mucosa extended above the gastroesophageal junction, measuring Prague C[X] M[X]. The gastroesophageal junction (top of the gastric folds) was at [X] cm and the diaphragmatic pinch at [X] cm from the incisors. [No visible lesions were seen / A visible lesion at [X] cm was biopsied and sent separately]. Four-quadrant biopsies were obtained every [2 / 1] cm from [X] cm to [X] cm from the incisors, with each level placed in a separate labeled container.
Gastritis / H. pylori Biopsies
Biopsies were obtained from the gastric antrum, incisura, and body and placed in separate labeled containers for histology. [An additional antral biopsy was placed in a rapid urease test.]
Dysphagia / Eosinophilic Esophagitis Biopsies
The esophagus showed [normal mucosa / rings / linear furrows / white exudates / ***]. Biopsies were obtained from the proximal and distal esophagus and placed in separate labeled containers to evaluate for eosinophilic esophagitis.
Duodenal Biopsies (Celiac Disease Evaluation)
The duodenal mucosa appeared [normal / scalloped / flattened with reduced folds]. [One / Two] biopsies were obtained from the duodenal bulb and [four / six] from the distal duodenum and placed in separate labeled containers.
Esophageal Dilation (Through-the-Scope Balloon)
A [benign-appearing stricture / Schatzki ring / ***] was identified at [X] cm from the incisors, estimated at [X] mm in diameter and [traversable / not traversable] with the gastroscope. A through-the-scope balloon was passed across the narrowing under direct vision and inflated sequentially to [X], [X], and [X] mm, holding each inflation for [X] seconds. Inspection after dilation showed [no mucosal disruption / mild superficial mucosal disruption] and no evidence of perforation.
Esophageal Dilation (Savary Bougie over a Guidewire)
A [long / tight / complex] stricture was identified at [X] cm from the incisors, estimated at [X] mm in diameter. A guidewire was passed through the endoscope into the gastric antrum, and the endoscope was withdrawn while the wire was held in position [under fluoroscopic guidance]. Savary dilators were passed over the wire sequentially from [X] to [X] Fr. Resistance was first felt at [X] Fr, and dilation was stopped at [X] Fr. Repeat endoscopy showed [no mucosal disruption / mild superficial mucosal disruption] and no evidence of perforation.
Bleeding Ulcer / Endoscopic Hemostasis
A [X]-cm ulcer was identified in the [duodenal bulb / gastric antrum / gastric body / ***] with [active spurting bleeding / active oozing / a nonbleeding visible vessel / an adherent clot] (Forrest [Ia / Ib / IIa / IIb]). [Dilute epinephrine (1:10,000), [X] mL, was injected in four quadrants around the lesion.] Definitive hemostasis was achieved with [[X] through-the-scope clips / bipolar thermal coagulation]. The site was observed for [X] minutes without further bleeding. [Gastric ulcer biopsies were obtained from the rim and sent to pathology.]
Esophageal Variceal Band Ligation
[Small / Medium / Large] esophageal varices were seen in the distal [X] cm of the esophagus, [with / without] red wale signs [and with active bleeding / and without active bleeding]. A band ligation device was attached to the endoscope, and [X] bands were placed, beginning at the gastroesophageal junction and progressing proximally. Hemostasis was confirmed at the end of the procedure.
Esophageal Food Impaction
A food bolus was found impacted at [X] cm from the incisors. [The bolus was gently advanced into the stomach after the lumen beyond it was assessed / The bolus was removed with a [retrieval net / snare / basket] [through an overtube]]. The underlying esophagus showed [a Schatzki ring / a stricture / features of eosinophilic esophagitis / no underlying abnormality] and [no mucosal injury / superficial mucosal injury] after clearance.
Charting Tips
- Record the Z-line in centimeters from the incisors. When a hiatal hernia is present, also record the diaphragmatic pinch, since the distance between the top of the gastric folds and the pinch defines the hernia length.
- State that the second portion of the duodenum was reached. If the examination stopped short, document where and why.
- Grade esophagitis by the Los Angeles classification (A to D) and describe Barrett's extent by Prague C and M lengths so surveillance examinations can be compared.
- Document biopsy sites, number, and containers. Separate containers by site (antrum vs body, each Barrett's level) let pathology map the findings.
- Biopsy gastric ulcers from the rim and base to exclude malignancy. Describe bleeding ulcers by location, size, and Forrest stigmata, and name the definitive hemostasis method; epinephrine injection should be paired with a mechanical or thermal method rather than used alone.
- For dilation, record the stricture location and estimated diameter, the dilator type, the starting and final sizes, the size at which resistance was first felt, and the post-dilation inspection. With bougies, dilation is usually limited to three successive sizes beyond the point of moderate resistance.
- For celiac disease evaluation, take 1 to 2 biopsies from the duodenal bulb and at least 4 from the distal duodenum, with the bulb specimens in a separate container.