Your Endoscopy Report: Key Findings and Recommendations - Gastroenterology and Hepatology

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Based on the endoscopy report you provided, here’s a detailed interpretation of the findings, implications, and recommendations:

Key Findings:
1. Esophagus: The esophagus appears normal, which is a positive sign, indicating no significant abnormalities such as strictures or lesions.

2. Esophagogastric Junction (EC junction): There is a mucosal break less than 5 mm, categorized as minimal change. This suggests mild reflux esophagitis, which is inflammation of the esophagus due to stomach acid.

3. Stomach:
- Fundus: Normal appearance.

- Body: A 1 mm sessile polyp was noted in the low body of the stomach. This type of polyp is generally benign, but it requires biopsy for further evaluation.

- Angularis: Normal appearance.

- Antrum: Mild inflammatory mucosa was observed, which is consistent with gastritis. A biopsy was taken for further analysis.

- Pylorus: Normal appearance.

4. Duodenum: Normal appearance, indicating no abnormalities in the first part of the small intestine.


Diagnosis/Impression:
1. Reflux Esophagitis, LA Grade A (Minimal Change): This indicates mild inflammation of the esophagus due to acid reflux. Lifestyle modifications and possibly medications (like proton pump inhibitors) may be recommended to manage symptoms.

2. Antral Gastritis, s/p biopsy: This suggests inflammation in the antrum of the stomach, which is often related to factors like Helicobacter pylori infection, chronic use of NSAIDs, or alcohol consumption. The biopsy will help determine the underlying cause.

3. Suspected Fundic Gland Polyp: The presence of a polyp in the stomach body requires monitoring. While most fundic gland polyps are benign, the biopsy will clarify its nature.


Recommendations:
- Follow-Up: It is crucial to have a follow-up appointment with a gastroenterologist (GI OPD) to discuss the biopsy results and further management.

- Helicobacter Pylori Eradication: If the biopsy indicates the presence of H. pylori, treatment will be necessary to eradicate the bacteria, which can contribute to gastritis and increase the risk of gastric cancer.

- Monitoring for Dysplasia or Early Malignancy: The report notes that dysplasia or early malignancy may be misdiagnosed with standard endoscopy. Therefore, close follow-up is essential, and chromoendoscopy may be recommended if there is a clinical suspicion of malignancy.

- Lifestyle Modifications: For reflux esophagitis, consider dietary changes, weight management, and avoiding triggers such as spicy foods, caffeine, and alcohol.


Conclusion:
Overall, the findings indicate mild conditions that require monitoring and further evaluation through biopsies. The absence of complications during the procedure is reassuring. It’s essential to maintain regular follow-ups and adhere to any treatment plans suggested by your healthcare provider. If you experience any new symptoms or worsening of existing symptoms, it is important to seek medical attention promptly.
If you have any further questions or concerns about your health or the implications of these findings, please feel free to reach out to your healthcare provider for personalized advice and support.