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Endoscopy normal report sample

Endoscopy report sample 2025

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The document is an endoscopic examination report for a lower gastrointestinal (GI) procedure, detailing patient information, indications for the procedure, equipment used, and findings from the examination. It includes sections on complications, sampling methods, and documentation of observations in various parts of the colon and ileum. The report also provides codes for normal and abnormal findings, along with comments and recommendations from the endoscopist.

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What are common findings in endoscopy?

An upper GI endoscopy can be used to identify disorders or problems such as: GERD (gastroesophageal reflux disease) Narrowing (strictures) or blockages. Larger than normal veins in your esophagus (esophageal varices) Redness and swelling (inflammation) and sores (ulcers)

What are the normal results of an endoscopy?

Normal Results The esophagus, stomach, and duodenum should be smooth and of normal color. There should be no bleeding, growths, ulcers, or inflammation.

What is the summary of endoscopy procedure?

Endoscopy (also called a gastroscopy) is a medical procedure that allows a doctor to observe the inside of the body without performing major surgery. An endoscope (fibrescope) is a long flexible tube with a lens at one end and a video camera at the other. The end with the lens is inserted into the patient.

How do you write an endoscopy report?

As recommended by the CAG, the endoscopy report should contain the following information: description of key findings, interventions, complications and sedation, description of symptoms of potential complications, instructions of actions to be taken and contact details if symptoms of complications arise, instructions

What is the normal report of an endoscopy?

Interpreting Endoscopy Results Normal Results: Healthy tissue with no signs of inflammation, infection, or abnormal growths. Abnormal Results: Polyps, cysts, or tumors may indicate benign or cancerous conditions. Inflammation may point to Crohns disease or ulcerative colitis.