DATE OF PROCEDURE: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
PREOPERATIVE INDICATION:
1. Gastrointestinal bleed.
2. Abnormal M2A capsule endoscopy
POSTOPERATIVE IMPRESSION:
1. Actively bleeding arteriovenous malformation at 90 cm, status post argon plasma coagulation.
2. No other abnormalities appreciated within the small bowel examination.
PROCEDURE PERFORMED: Small bowel enteroscopy.
ANESTHESIA: MAC.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: After overnight fasting, informed consent was obtained. The risks, benefits and possible complications of small bowel enteroscopy were explained to the patient and the patient agreed to undergo the procedure. Consent was obtained.
The patient was transferred to the endoscopy suite and placed in the left lateral recumbent position, placed on appropriate monitors and given IV sedation as described above.
Once adequately sedated, a pediatric variable stiffness colonoscope was introduced into the oropharynx under direct technique. The esophagus was intubated. Air was insufflated and the scope was advanced into the stomach.
The scope was then easily advanced into the small bowel. At approximately 95 cm, there was fresh blood appreciated which was extensively lavaged. The bleeding stopped spontaneously. The specific source was not identified at this time.
The pediatric colonoscope was then inserted to its full length. No other abnormalities were appreciated. The scope was then withdrawn. At this time, a small bowel enteroscope was then inserted as previously described and advanced to 2 m. No bleeding was identified during this examination to 2 m.
Upon withdrawing the scope, at approximately 90 cm where there was previously identified fresh blood, a rather large arteriovenous malformation was identified.
At this point, we attempted to use argon plasma coagulation through the small bowel enteroscope; however, the catheter was not long enough.
The small bowel enteroscope was removed and the pediatric variable stiffness colonoscope was then reinserted and the area was once again located at approximately 90 cm. There was no evidence of active bleeding upon reinsertion.
At this point, using argon plasma coagulation at 40 watts and 1 L flow rate, APC therapy was applied to this area. Excessive air and secretions were then aspirated and the scope was removed.
The patient tolerated the procedure well. There were no apparent complications. The patient will be transferred to the endoscopy recovery room in stable condition.
IMPRESSION:
1. Actively bleeding arteriovenous malformation at 90 cm, status post argon plasma coagulation.
2. No other abnormalities appreciated within the small bowel examination.
RECOMMENDATIONS: At this time, a small bowel arteriovenous malformation was identified and was actively bleeding at the time of this procedure. Argon plasma coagulation therapy was performed on this lesion. This lesion may correspond to the small bowel arteriovenous malformation, which was identified on the M2A capsule study. There was, however, a small polyp located on the M2A study. This lesion was not identified during this examination. The patient is to continue taking iron replacement therapy. The patient should refrain from aspirin or NSAID consumption. We will continue to monitor the patient’s hemoglobin. The patient will be referred for a double balloon enteroscopy for further assessment of the small bowel.
