(Colo + Endo)Scopy
Upper GI endoscopy
After obtaining informed consent, the endoscope was passed under direct vision.
Findings:
- The oropharynx was normal.
- The upper third of the esophagus, middle third of the esophagus and lower third of the esophagus were normal.
Biopsies were obtained with cold forceps for histology in the middle third of the esophagus.
- The Z-line was regular and was found 40 cm from the incisors.
- Minimal inflammation was found in the stomach. Biopsies were taken with a cold forceps for histology. Estimated
blood loss was minimal.
- The examined duodenum was normal. Biopsies were taken with a cold forceps for histology. Estimated blood loss
was minimal.
- The cardia and gastric funds were normal on retroflexion.
Colonoscopy
Findings:
- The perianal and digital rectal examinations were normal. Pertinent negatives include normal sphincter tone, no
palpable rectal lesions and normal prostate (size, shape, and consistency).
- A patchy area of mucosa in the terminal ileum was mildly ulcerated. Biopsies were taken with a cold forceps for
histology. Estimated blood loss was minimal.
- Two sessile polyps were found in the descending colon and ascending colon. The polyps were 4 to 6 mm in size.
These polyps were removed with a cold snare. Resection and retrieval were complete. Estimated blood loss was
minimal.
- A few small and large-mouthed diverticula were found in the entire colon.
- Normal mucosa was found in the entire colon. Biopsies were taken with a cold forceps for histology.
- The retroflexed view of the distal rectum and anal verge was normal and showed no anal or rectal abnormalities.
Impression:
- Ulcerated mucosa in the terminal ileum (causes). Biopsied.
- Two 4 to 6 mm polyps in the descending colon and in the ascending colon, removed with a cold snare
Resected and retrieved.
- Diverticulosis in the entire examined colon.
- Normal mucosa in the entire examined colon. Biopsied
- The distal rectum and anal verge are normal on retroflexion view.
Estimated Blood Loss:
Estimated blood loss was minimal.
Recommendation:
- Discharge patient to home.
- Resume previous diet.
- Await pathology results.
- Return to my office in 2 weeks.