For refractory epigastric abdominal spasm and possible heartburn symptoms despite omeprazole and ranitidine therapy. Prior history of peptic ulcer and a "large" hiatal hernia performed elsewhere.
DESCRIPTION OF PROCEDURE
Time-out was called. Consent signed. IV sedation performed. The forward-viewing endoscope was passed into the mouth of the esophagus, stomach, then to the second portion of the duodenal without difficulty. Upon withdrawal, the following findings were noted.
Duodenum: The first and second portion of the duodenum were normal in appearance without ulcer, erosion, or villous atrophy. No specimens obtained.
Stomach: The stomach was empty of all contents. The entire stomach was visualized including a retroflexed view of the cardia. There was no gastritis or ulcer. Gastric folds were normal. There is also no hiatal hernia identified.
Esophagus: The squamocolumnar junction was distinct, regular in appearance and located 38 cm distal to the incisor teeth. There is no hiatal hernia appreciated and if present …show more content…
The inmate was questioned to me as to what the cause of the epigastric spasm and heartburn symptoms were due to. He does have nocturnal retrosternal burning and some regurgitation. I explained that the fact that the endoscopy being normal may be a result of acid suppression. Again, the differential diagnosis remains broad would have to include non ulcer dyspepsia, less likely gallbladder disease, esophageal spasm, or this could be nonerosive reflux. In order to determine whether or not he is having reflux on medical therapy, I might suggest scheduling him for an endoscopy with esophageal pH capsule while on therapy including his current drugs omeprazole and Zantac to be done at Maria Parham Hospital along with high-resolution manometry to rule out esophageal spasm disorder. Please consider this, this can be arranged through my