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Final Upper Endoscopy Report Form

The document is an endoscopic examination report for an upper GI endoscopy procedure, detailing patient information, indications, and equipment used. It includes sections for documenting findings in the esophagus, stomach, and duodenum/jejunum, as well as any complications or sampling performed. The report concludes with comments and recommendations from the endoscopist.

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bhuvanagirivinod100
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© © All Rights Reserved
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20 views

Final Upper Endoscopy Report Form

The document is an endoscopic examination report for an upper GI endoscopy procedure, detailing patient information, indications, and equipment used. It includes sections for documenting findings in the esophagus, stomach, and duodenum/jejunum, as well as any complications or sampling performed. The report concludes with comments and recommendations from the endoscopist.

Uploaded by

bhuvanagirivinod100
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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ENDOSCOPIC EXAMINATION REPORT: UPPER GI ENDOSCOPY

Date of procedure: ...................................... Case Number: .................................

Patient and client information:


(card or stamp)

PROCEDURE(S): __________________________________________________________
Indication(s) for procedure: __________________________________________________________
Endoscope(s) used: __________________________________________________________
Forceps/retrieval device(s) used: __________________________________________________________

PROBLEMS/COMPLICATIONS: None 
Perforation  Excessive bleeding  Anesthetic complications  Excessive time  Other 
Comments: ___________________________________________________________________________
 Unable to complete full examination: why? _____________________________________________
 Unable to obtain adequate biopsies: why? _____________________________________________
 Unable to retrieve foreign object: why? _____________________________________________
 Visualization obscured why? _____________________________________________

SAMPLING: Biopsy  Brush cytology  Washing  Aspiration  Foreign body retrieved 

DOCUMENTATION: Video  Photographs 


ESOPHAGUS Normal  Foreign body  Mass  Stricture  Hiatal hernia 
Lesion Code Comments (include location)
Hyperemia/vascularity
Discoloration
Friability
Hemorrhage
Erosion/ulcer
Contents (mucus/bile/food)
Dilation
Gastroesophageal sphincter
Other

Code: Normal = 0 Mild = 1 Moderate = 2 Severe = 3


STOMACH Normal  Foreign body  Mass  Polyp(s)  Parasite(s) 
Site(s) of lesions: Fundus  Body  Incisura  Antrum  Pylorus 
Site(s) of biopsies: Fundus  Body  Incisura  Antrum  Pylorus 
Lesion Code Comments (include location)
Can’t inflate lumen
Hyperemia/vascularity
Edema
Discoloration
Friability
Hemorrhage
Erosion/ulcer
Contents (mucus/bile/food)
Gastroesophageal sphincter
Passing scope through
pylorus
Other

DUODENUM/JEJUNUM Normal  Foreign body  Mass  Polyp  Parasite(s) 


How far was the tip of the scope advanced?_______________________________
Was/were the papilla(e) seen? Yes  (which? _____________) No 
Lesion Code Comments (include location)
Can’t inflate lumen
Hyperemia/vascularity
Edema
Discoloration
Friability
Texture
Hemorrhage
Erosion/ulcer
Lacteal dilatation
Contents (mucus/bile/food)
Other
Code: Normal = 0 Mild = 1 Moderate = 2 Severe = 3

Comments and Recommendations: _________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Endoscopist signature _____________________

This standard form was developed by the WSAVA Gastrointestinal Standardization


Group (Drs Washabau, Willard, Hall, Jergens, Day, Mansell, Wilcox, Minami,
Guilford, and Biltzer) with sponsorship from Hill’s Pet Nutrition

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