Upper endoscopy and colonoscopy

PROCEDURE:                                             Upper endoscopy and colonoscopy.

INDICATIONS:                                             Iron deficiency anemia.

PROCEDURE IN DETAIL:                                    Indications, risks, benefits, alternatives, and limitations were explained to the patient.  He gave an informed consent.  He was then brought to the endoscopy room.  Anesthesia provided sedation.  Scope was advanced into esophagus, stomach, and duodenum.  Third portion, second portion, and bulb was normal.  Pylorus was normal.  Antral gastritis was noted and biopsy was taken.  On retroflexion, lesser curvature, greater curvature, fundus, and cardia were normal.  Stomach insufflated very well.  No abnormal folds were seen.  There was a small nodule in the antrum next to the pylorus, which was biopsied.  Otherwise, rest of the stomach was grossly negative.  Esophagogastric junction was normal.  Esophageal mucosa was normal.  Procedure completed.  The patient tolerated the procedure well and then I reintroduced the scope all the way down to the small bowel in order to take biopsies to rule out celiac sprue and then the procedure was completed.

PROCEDURE:  Colonoscopy.

The colonoscope was advanced into the rectum all the way to the cecum and terminal ileum.  Photographs were taken for documentation.  Mucosa was then examined.  On withdrawal. minimal liquid and pasty stool throughout the colon as much as possible was cleaned out.  Small lesions or flat lesions could have been missed.  The terminal ileum, the cecum, the ascending colon, transverse colon, descending colon, sigmoid colon, and rectum were examined.  Retroflexion was done the rectum.  Over 6 minutes was taken to evaluate the colon on withdrawal.  Findings were that of grossly negative terminal ileum and grossly negative colon, small-to-moderate internal hemorrhoids.  Procedure completed.  The patient tolerated the procedure well.

IMPRESSION:  Iron deficiency anemia.  Endoscopy showed gastritis.  Biopsy taken a small nodule in the antrum.  Biopsy taken.  Small bowel biopsy taken to rule out celiac sprue.  Colonoscopy grossly negative.  Terminal ileum grossly negative.  Small-to-moderate internal hemorrhoids.

PLAN:  The patient can be discharged home.  Follow up in my office next week to review the biopsies.  Check the celiac sprue workup and then we will plan small bowel series followed by capsular endoscopy.