Endoscopy Templates

[comment memo="Generic EGD Template"]
EGD Report:
Oropharynx: Normal
Esophagus: Proximal, mid, and distal esophagus appeared normal.
EG-Junction: The Z-line appeared regular and was identified at 40 cm from the incisors. 
Cardia:
Hill Grade 1 Hiatus - Wall-like gastroesophageal flap valve, always with tight closure round the endoscope
Hill Grade 2 Hiatus - Gastroesophageal flap valve less marked, with respiration-dependent incomplete closure of the cardia round the endoscope
Hill Grade 3 Hiatus - Gastroesophageal flap valve hardly present any more, no closure around the endoscope
Hill Grade 4 Hiatus - Gastroesophageal flap valve no longer present, permanent opening of the esophagogastric junction
Fundus: Normal
Body: Mildly erythematous mucosa. Random biopsies were obtained with cold biopsy forceps at the lesser and greater curvatures of the body for histopathologic review / H. pylori testing [3].
Antrum: Mildly erythematous mucosa. Random biopsies were obtained with cold biopsy forceps at the pre-pyloric region [1] and incisura [2] for histopathologic review / H. pylori testing.
Pylorus: Normal
Duodenal Bulb: Normal
2nd Portion: Normal
3rd Portion: Normal
Jejunum:
Gastric Pouch:
GJ Anastomosis:

[comment memo="Jovani EGD Template"]
ENDOSCOPIC FINDINGS (EGD):
ESOPHAGUS: regular for course and diameter. The proximal, mid and distal esophagus were normal.  The gastroesophageal junction (GEJ) was characterized by a regular Z-line. No varices. No esophagitis. No hiatal hernia. 
STOMACH: The stomach was viewed in antegrade and retrograde positions.  The mucosa was endoscopically normal.  
DUODENUM: The first and second portions of the duodenum were normal.

[comment memo="EGD Biopsy Templates"]
EGD biopsies (Tsirlin):
Random biopsies were obtained with cold biopsy forceps in the duodenum for histopathologic review [1].
Random biopsies were obtained with cold biopsy forceps at the pre-pyloric region and incisura for histopathologic review / H. pylori testing [2].
Random biopsies were obtained with cold biopsy forceps at the lesser and greater curvatures of the body for histopathologic review / H. pylori testing [3].
Random biopsies were obtained with cold biopsy forceps at the fundus for histopathologic review [3].
Targeted biopsies were obtained with cold biopsy forceps for histopathologic review [4].

EGD biopsies (Shiratori):
Random biopsies were obtained with cold biopsy forceps at the pre-pyloric region [1] and incisura [2] for histopathologic review / H. pylori testing.
Random biopsies were obtained with cold biopsy forceps at the lesser and greater curvatures of the body for histopathologic review / H. pylori testing [3].

EGD biopsies (Porat):
Random biopsies were obtained with cold biopsy forceps in the duodenum for histopathologic review [1].
Random biopsies were obtained with cold biopsy forceps at the pre-pyloric region and incisura for histopathologic review / H. pylori testing [2].
Random biopsies were obtained with cold biopsy forceps at the lesser and greater curvatures of the body for histopathologic review / H. pylori testing [3].
Random biopsies were obtained with cold biopsy forceps at the mid-esophagus for histopathologic review [4].

No blood:
There was no presence of fresh or active blood or clot. There was no active bleeding noted. 

[comment memo="PEG Templates"]
PULL technique: Optimal site for PEG tube insertion was located along mid anterior wall by identification of light transillumination and 1:1 finger palpation. A 20 French Boston Scientific EndoVive PEG tube was placed using PULL technique under direct visualization. Internal bumper position was confirmed via second look endoscopy without evidence of bleeding. The external bumper was placed at [ ] cm, lightly touching the skin.  

PUSH technique: Optimal site for PEG tube insertion was located along mid anterior wall by identification of light transillumination and 1:1 finger palpation. A 20 French Cook Flow-20-Push-I-S PEG tube was placed using PUSH technique under direct visualization. The external bumper was placed at [] cm, lightly touching the skin.  

Post-PEG Recommendations:
- May start administering water, medications, and tube feeds in 3 hours 
- PPI suspension 40 mg daily via PEG
- Routine PEG care as per protocol 
- Maintain abdominal binder and mittens to prevent patient from pulling out PEG tube 
- Do not insert Foley catheter/replacement PEG tube if removed in the next 4 weeks. Call GI

[comment memo="Motility Templates"]
EndoFLIP
Using standard technique, EndoFLIP performed with good placement across the EGJ and FLIP measurements obtained. 
At 40 cc, Diameter:mm, Distensibility:, Pressure:mm/Hg
At 50 cc, Diameter:mm, Distensibility:, Pressure:mm/Hg
At 60 cc, Diameter:mm, Distensibility:, Pressure:mm/Hg
At 70 cc, Diameter:mm, Distensibility:, Pressure:mm/Hg

GEJ Distensibility: Distensibility Low? 
Repetitive Antegrade Contractions: Are RAC's Present? 
Repetitive Retrograde Contractions: Are RRC's Present? 
Contractility: Is contractility present? 

BRAVO:
Endoscope was withdrawn and Bravo pH monitoring device; system (Lot # ***, ID # ***) was introduced and placed at __ cm from incisors. Placement confirmed via second look endoscopy  

[comment memo="Generic Colonoscopy Template"]
Colonoscopy Report:
Anal Canal: Internal hemorrhoids identified on forward views.
Rectum: Internal hemorrhoids identified on retroflexion views.
Sigmoid Colon:
Descending Colon:
Splenic Flexure:
Transverse Colon:
Hepatic Flexure:
Ascending Colon:
Cecum:
Ileocecal Valve:
Ileum:

Normal
Few / Numerous scattered small to wide mouthed diverticula identified

[comment memo="Jovani Colonoscopy Template"]
COLONOSCOPY FINDINGS:
A pediatric colonoscope was inserted into the rectum and advanced to the terminal ileum. Subsequently, the terminal ileum, cecum, ascending, transverse, descending, and sigmoid colon were evaluated. The rectum and anal canal were evaluated in forward and retroflexion views. Non-bleeding internal hemorrhoids were identified. The rectal mucosa appeared otherwise normal. The pediatric colonoscope was then withdrawn and the procedure was concluded.

[comment memo="Segmental Colonic Biopsies"]
Colon segmental biopsies (w/ cecum):
Random biopsies were obtained with cold biopsy forceps in the ileum for histopathologic review [1].
Random biopsies were obtained with cold biopsy forceps in the cecum for histopathologic review [2].
Random biopsies were obtained with cold biopsy forceps in the ascending colon for histopathologic review [3].
Random biopsies were obtained with cold biopsy forceps in the transverse colon for histopathologic review [4].
Random biopsies were obtained with cold biopsy forceps in the descending colon for histopathologic review [5].
Random biopsies were obtained with cold biopsy forceps in the sigmoid colon for histopathologic review [6].
Random biopsies were obtained with cold biopsy forceps in the rectum for histopathologic review [7].

Colon segmental biopsies (w/o cecum):
Random biopsies were obtained with cold biopsy forceps in the ileum for histopathologic review [1].
Random biopsies were obtained with cold biopsy forceps in the ascending colon for histopathologic review [2].
Random biopsies were obtained with cold biopsy forceps in the transverse colon for histopathologic review [3].
Random biopsies were obtained with cold biopsy forceps in the descending colon for histopathologic review [4].
Random biopsies were obtained with cold biopsy forceps in the sigmoid colon for histopathologic review [5].
Random biopsies were obtained with cold biopsy forceps in the rectum for histopathologic review [6].

[comment memo="Other"]
Tattoo: 
Approximately 1 fold distal to the lesion, site marked with SpotTattoo using Boston Scientific Interject needle.  

Biopsy: 
The polyp was resected with cold biopsy forceps and sent for histopathologic review [].  

Clipping:
One Boston Scientific Resolution 360 endoclip was placed for prophylactic hemostasis. 

[comment memo="Polypectomies"]
Typical adenoma snare:
A 5 mm polyp (Paris Classification: 0-Is, NICE Classification: II, JNET Classification: 2a) was identified in the x colon. The polyp was resected with 10 mm Boston Scientific Captivator cold snare, was retrieved via suction, and sent for histopathologic review []. 

Polyp classification (basic) + snare:
A xx mm/cm polyp (Paris Classification: 0-Ip/0-Isp/0-Is/0-IIa/0-IIb/0-IIc/0-III, NICE Classification: I/II/III, JNET Classification: 1, 2a, 2b, 3) was identified in the xx colon. The polyp was resected with 10/15/20/25/33/35 mm Boston Scientific Captivator cold snare, was retrieved via suction, and sent for histopathologic review []. 

ENDOSCOPIC MUCOSAL RESECTION (EMR)
An adult colonoscope with a cap was used. The colonoscope was advanced until the cecum. At XXX there was a polypoid lesion / lateral spreading tumor (Paris XXX, NICE type XXX, Kudo pit pattern XXX) measuring XXX mm. Decision was made to proceed with endoscopic mucosal resection (EMR). The lesion was lifted with submucosal injection of EverLift solution. Then, a XXX mm snare was used for en-block / piecemeal mucosal resection. At the end of the resection, no residual polyp was seen. Soft tip coagulation of the margins was performed to reduce the risk of polyp recurrence. The mucosal defect was closed with XXX clips. All pieces were retrieved for pathological examination. 

EMR:
A xx mm/cm polyp (Paris Classification: 0-Ip/0-Isp/0-Is/0-IIa/0-IIb/0-IIc/0-III, NICE Classification: I/II/III, JNET Classification: 1, 2a, 2b, 3, Kudo Pit Pattern [on NBI]: I/II/III-s/III-l/IV/V-i/V-n) identified in the proximal/mid/distal xx colon. Submucosal injection was performed with EverLift gel solution resulting in adequate mucosal lift. The polyp was resected en-block / in piece-meal by snare cautery using 15/20/25/33/35 mm Boston Scientific Captivator hot snare utilizing EndoCut Q mode, retrieved via suction into transparent distal attachment cap with endoscope withdrawn / *** RothNet / and sent for histopathologic review []. *** Boston Scientific Resolution 360 / Ultra endoclips were deployed over the endoscopic mucosal resection (EMR) site for prophylactic hemostasis.   

[comment memo="Advanced Procedures"]
Full thickness resection (FTR)
In the rectum, at about XXX cm from the anal verge there was a scar from previous treatments, and a residual polypoid area of about 12 mm. The residual polypoid area appeared sessile (Paris Is; NICE type 2; pitt-pattern IIIs). The area was marked with soft-tip coagulation, and then full-thickness resection (FTR) was performed with the full-thickness resection device (FTRD). The marked area was identified. A grasper forcep was used to pull the lesion into the cap, and then the over-the-scope clip was deployed, followed by full-thickness resection of the captured tissue. The tissue was then retrieved and sent for pathologic evaluation. At control endoscopy, the clip was in good position, and there were no signs of perforation or active bleeding.

[comment memo="ENDOSCOPIC ULTRASOUND"]
ENDOSCOPIC ULTRASOUND (EUS) FINDINGS:
ENDOSCOPIC FINDINGS (EGD):
Endoscopic examination was limited because of oblique-viewing echoendoscope. 
First, a standard EGD was performed.
ESOPHAGUS: regular for course and diameter. The proximal, mid and distal esophagus were normal.  The gastroesoohageal junction (GEJ) was characterized by a regular Z-line. No varices. No esophagitis. Small hiatal hernia. 
STOMACH: The stomach was viewed in antegrade and retrograde positions.  The mucosa was endoscopically normal.  
DUODENUM: The first and second portions of the duodenum were normal.

ENDOSONOGRAPHIC FINDINGS:
PANCREAS: There were / were no foci, strands, lobularity, dilated side branches, parenchymal calcification, irregular out border of the gland. The parenchyma was slightly hyperechoic, with decreased visualization of the splenic vessels suggestive of fatty infiltration. No clear signs of masses or cysts in the pancreatic parenchyma. The main pancreatic duct measured @@ mm in the head/neck, @@ mm in the body/tail.  The duct wall was/was not echogenic. 
There was a single anechoic lesion / There were several anechoic lesions consistent with pancreatic cyst / cysts located in the uncinate / head / neck / body / tail.  The largest cyst was located in the uncinate / head / neck / body / tail and measured @@ mm x @@ mm.  It was unilocular / multilocular.  The septations measured @@ mm.  It was / was not well defined.  It had a thin / thick wall.  There was / was not any solid component.  There was / was not calcification within the cyst.  The cyst did / did not / did not clearly communicate with the main pancreatic duct There were additional smaller cysts located in the head / uncinate which measured @@ mm; body / tail which measured @@ mm.  None of these additional cysts had any concerning features.  

BILE DUCT: The bile duct was traced from the hilum to the ampulla.  It measured @@ mm in diameter. The duct wall was thin.  There was / was no echogenic material within the duct.  The gallbladder was normal / contained echogenic material consistent with gallbladder stones / polyps.

LYMPH NODES: There were no perigastric or peripancreatic nodes.
LEFT ADRENAL: The left adrenal gland was normal.
AORTA AND CELIAC AXIS:The visualised portion of the aorta and celiac axis were normal.
LIVER: The visualised portion of the left lobe of the liver was normal.
SPLEEN: The visualised portion of the spleen was normal.

FINE-NEEDLE BIOPSY:
Endoscopic ultrasound guided fine needle biopsy of the mass / cyst in the uncinate / head / neck / body / tail was performed with a 19/22/25 guage needle (XXX passes).  The sample was submitted for cyst fluid CEA / amylase / cytology / molecular markers / pathology evaluation.

[comment memo="STANDARD ERCP"]
A scout film of the abdomen was performed. Previously placed stent was visible. Surgical clips were visible. An adult duodenoscope was used.  Limited views of the esophagus, stomach and duodenum were unremarkable.  The papilla was normal. The stent was removed with a rat-tooth forceps. There was evidence of a prior biliary sphincterotomy.

A sphincterotome / 9-12 mm stone retrieval balloon catheter preloaded with a 0.025 inch guidewire was used for biliary ductal cannulation. The guidewire was then advanced into the right intrahepatic duct. Cholangiogram was performed. I personally interpreted the images. Cholangiogram showed correct position of the guidewire in the common bile duct (CBD) and common hepatic duct (CHD). Two small filling defects were seen in the distal common bile duct (CBD).

A biliary sphincterotomy was performed using a 20 mm cutting wire and blended electrosurgical current.

A 9-12 mm stone retrieval balloon was used to sweep the CBD with flow of contrast / sludge / stones. 

Occlusion cholangiogram showed CBD stricture with upstream dilation of the CBD, CHD and intrahepatics. The common bile duct and common hepatic duct were approximately XXX mm.

At the end of the procedure, occlusion cholangiogram was performed and did not show any filling defects.

A double pig-tail / straight plastic stent (7 Fr, 7 cm) was placed over-the-wire to protect the bile duct while awaiting cholecystectomy. There was excellent bile and contrast drainage through the lumen of the stent.

A fully-covered self-expanding metal stent (10 mm x XXX mm) was placed over the wire. There was an impressive waist in the middle of the stent. There was excellent drainage of contrast after stent placement.

The duodenoscope was then completely withdrawn from the patient and the procedure completed.

For technical reasons, the fluoroscopic images could not be uploaded in this note, but are available in SCM.

RECOMMENDATIONS (vary as needed):
- Post ERCP care in PACU as per protocol.
- Antibiotics for 5 days (ciprofloxacin 500 mg BID; metronidazole 500 mg TID)
- Resume regular diet as tolerated
- Patient will require repeat ERCP with removal and/or exchange of biliary stent in 4 weeks (we will organize)