DATE:
1 November 2024
PROCEDURE:
"Gastroscopy"
PRE-PROCEDURE DIAGNOSIS:
- Chronic gastroesophageal reflux disease (GERD)
- Dysphagia
- Rule out Barrett's oesophagus
POST-PROCEDURE DIAGNOSIS:
- Erosive oesophagitis, Grade B
- Small hiatal hernia
HISTORY OF PRESENTING ILLNESS:
Mrs. Eleanor Vance, a 68-year-old female, was referred by her GP for evaluation of persistent dysphagia and worsening heartburn despite maximal medical therapy. Her symptoms started approximately 18 months ago, initially presenting as occasional heartburn after meals, which has progressed to daily occurrences and now includes difficulty swallowing solid foods. She reports occasional regurgitation but denies any weight loss, anaemia, or melaena. She had a previous gastroscopy 5 years ago which showed mild gastritis.
PAST GI HISTORY:
- Mild gastritis (5 years ago)
- Irritable Bowel Syndrome (IBS) – diagnosed 10 years ago, managed with diet.
PAST HISTORY:
- Hypertension, controlled with medication
- Type 2 Diabetes Mellitus, well-controlled with diet and metformin
- Cholecystectomy (15 years ago)
MEDICATIONS:
- Esomeprazole 40 mg once daily
- Amlodipine 5 mg once daily
- Metformin 500 mg twice daily
ALLERGIES:
- Penicillin (rash)
FAMILY HISTORY:
Her mother had a history of colon polyps. Her father passed away due to myocardial infarction and had no known GI conditions. No family history of oesophageal or gastric cancer.
SOCIAL HISTORY:
Mrs. Vance is a retired primary school teacher, living with her husband in a detached house. She is fully mobile and independent. She reports no current tobacco use, occasional social alcohol consumption (1-2 units per week), and denies illicit substance use.
PHYSICAL EXAM:
"The abdomen was soft, non-tender, with no hepatosplenomegaly or masses. Cardiovascular, respiratory, lymph node, and dermatological examinations were normal."
INVESTIGATIONS:
- Oesophageal manometry (3 months ago): showed hypotensive lower oesophageal sphincter (LOS).
- pH study (2 months ago): demonstrated abnormal acid exposure.
- Blood tests (1 month ago): unremarkable, no anaemia.
CONSENT:
"Informed consent was obtained after having reviewed the rationale and alternatives for the procedure as well as its risks, which include but are not limited to: sedation-related adverse effects, aspiration, post-procedural chest or abdominal discomfort, less than one percent risk of perforation with dilation potentially requiring surgical intervention and infection."
SEDATION:
"Intravenous conscious sedation consisting of midazolam 3 mg and fentanyl 50 mcg."
PROCEDURE:
"After a time out, with the patient in the left lateral decubitus position, the gastroscope was inserted into the oropharynx and carefully advanced with direct visualization to the level of the cricopharyngeus. Esophageal intubation was performed without difficulty. The gastroscope was gradually advanced and the entire esophageal mucosa was carefully visualized. The gastroscope was further advanced into the stomach and the mucosa of the gastric fundus, body, and antrum were slowly surveyed. The gastroscope was subsequently advanced into the duodenum for evaluation of the first and second portions. Satisfactory mucosal views were achieved with the use of irrigation and suctioning of all pools of residue, mucus and fluid, and retroflection. There was evidence of erosive oesophagitis (Los Angeles Classification Grade B) in the distal oesophagus and a small sliding hiatal hernia. Biopsies were taken from the distal oesophagus to rule out Barrett's oesophagus and from the gastric antrum for *Helicobacter pylori*. The gastroscope was removed and the patient was returned to the recovery room having tolerated the procedure well."
ASSESSMENT AND PLAN:
Assessment: Mrs. Vance presents with severe GERD and dysphagia, likely due to erosive oesophagitis and a small hiatal hernia, confirmed by gastroscopy. Biopsies have been taken to assess for Barrett's oesophagus and *H. pylori* infection.
Plan:
1. Continue Esomeprazole 40 mg daily. Increase to twice daily if symptoms persist.
2. Review biopsy results when available. If Barrett's oesophagus is confirmed, discuss surveillance protocol.
3. Consider referral for fundoplication if symptoms remain refractory to medical management and lifestyle changes.
4. Advise on lifestyle modifications: elevating head of bed, avoiding late-night meals, weight management.
5. Follow-up appointment in 6-8 weeks to discuss results and further management.
