CONTACTS 

SUBJECTS
Achalasia Diagnosis Requires Additional Test Esophegeal Manometry Ex

1303 -
1303 -    ..
1304 - Summary/Objective
1305 -
130501 - Follow up ref SDS 35 0000. ref SDS 34 0000.
130502 -
130503 - Letter from the Doctor confirms the biopsy on 051209 was negative for
130504 - cancer and infection in the esophagus and stomach. ref SDS 0 L85K  He
130505 - has ordered another test to further esatablish diagnosis of achalasia
130506 - and which will be performed in Sacramento. ref SDS 0 696L  A second
130507 - letter received from the VA schedules a meeting on 060131 in the
130508 - Martinez facility, ref SDS 0 OP5G, so this seems not to be the
130509 - procedure ordered by Doctor Lee, and there is no explanation of the
130510 - purpose for meeting on 060131.  Sent Kim a letter requesting
130511 - assistance on clarifying the purpose of the meeting on 060131.
130512 - ref SDS 0 617N
130513 -
130514 -     [On 060112 Kim clarifies that the VA changed the schedule of
130515 -     meeting with the plastic surgeon to review lipoma issue from
130516 -     060207 ahead to 060131. ref SDS 36 DP5O
130517 -
130518 -
130519 -
130520 -
130521 -
130522 -
130524 -  ..
1306 -
1307 -
1308 - Progress
1309 -
130901 - Received ref DRT 1 0001 dated 060106 from the doctor in Gastroentology
130902 - Clinic at the VA in Martinez, CA, and following the meeting on 051209.
130903 - ref SDS 30 PRRT
130905 -  ..
130906 - The doctor says...
130907 -
130908 -    1.  You had an examination of your esophagus, stomach, and duodenum
130909 -        (EGD) at the Martinez VA on 9 December 2005. ref DRT 1 0001
130910 -
130911 -    2.  The biopsies from your esophagus and stomach showed NO cancer
130912 -        or infection. ref DRT 1 646F
130914 -  ..
130915 - This report supports the explanation presented during the meeting with
130916 - the primary care physician on 051222. ref SDS 33 FT6M
130918 -  ..
130919 - The doctor continues...
130920 -
130921 -    3.  This supports the diagnosis of achalasia. ref DRT 1 P46I
130923 -         ..
130924 -    4.  The next step will be to obtain an esophageal manometry
130925 -        examination at the Sacramento VAMC.  This is a measurement of
130926 -        the pressures produced by your esophagus at the time you
130927 -        swallow.  It is the gold standard for making the diagnosis of
130928 -        achalasia.  It requires special equipment which is not
130929 -        available at the Martinez VA facility.  I have already
130930 -        requested the appointment.  The Sacramento VAMC will contact
130931 -        you directly. ref DRT 1 646L
130932 -
130933 -            [On 060125 manometer test scheduled for 060209 0800.
130934 -            ref SDS 37 GG9I
130936 -             ..
130937 -            [On 060202 confirmed understandings from the meeting, and
130938 -            notified of plan to have lipoma removed. ref SDS 38 G45S
130940 -             ..
130941 -            [On 060209 meeting at VA Mather AFB in Sacramento, test was
130942 -            postponed until 060223 due to equipment failure.
130943 -            ref SDS 39 OW6M
130945 -  ..
130946 - On 051209 the doctor indicated a preliminary diagnosis is achalasia,
130947 - ref SDS 30 5B5K, and the letter today supports that initial view, and
130948 - is supported by the biopsy, show below, ref SDS 0 VW45, pending
130949 - another test to be performed in Sacramento.
130951 -  ..
130952 - Doctor's report on examination and endoscopy test on 051209...
130953 -
130954 -    TITLE:  EGD 60111
130955 -    DATE OF NOTE:  DEC 09, 2005@11:30   ENTRY DATE:  DEC 12, 2005@23:05
130956 -    AUTHOR:  LEE, RANDALL E             EXP COSIGNER:
130957 -    URGENCY:                            STATUS:  COMPLETED
130958 -
130959 -    *** EGD 60111 Has ADDENDA ***
130961 -     ..
130962 -    Date of Birth:  03/01/45
130964 -     ..
130965 -    NAME OF PROCEDURE:
130966 -
130967 -        1.  Esophagogastroduodenoscopy
130968 -
130969 -        2.  Endoscopic biopsy
130970 -
130972 -     ..
130973 -    ATTENDING PHYSICIAN:
130974 -
130977 -     ..
130978 -    INDICATIONS:
130979 -
130980 -        This is a 60-year-old man seen earlier this month for
130981 -        evaluation of a question of achalasia.  He has had a
130982 -        decade-long history of symptoms of regurgitation and vomiting
130983 -        of undigested food.  He has no other known medical problems.
130984 -        Upper GI series performed on 07/14/05, showed a markedly
130985 -        dilated mid and lower esophagus without evidence of peristaltic
130986 -        contractions and sharp narrowing of the GE junction.
130988 -         ..
130989 -        In preparation for this examination, he was advised to ingest
130990 -        only clear liquids for 48 hours.
130991 -
130993 -     ..
130994 -    TODAY ON EXAMINATION:
130995 -
130996 -        He is awake, alert and oriented.
130997 -
130998 -        CHEST:    Clear.
130999 -        HEART:    Regular rate and rhythm; without murmurs.
131000 -        ABDOMEN:  Benign.
131001 -
131003 -     ..
131004 -    CONSENT:
131005 -
131006 -        The risks, benefits and alternatives of this procedure,
131007 -        including but not limited to the risks of bleeding and bowel
131008 -        perforation was explained to the patient.  The patient
131009 -        understood and provided written informed consent.
131011 -     ..
131012 -    INTRAVENOUS MEDICATION:
131013 -
131014 -        1.  Diphenhydramine 15 mg.
131015 -        2.  Fentanyl 200 mcg,
131016 -        3.  Midazolam 4 mg
131017 -
131019 -     ..
131020 -    PROCEDURE:
131021 -
131022 -        In the Martinez VA BI Endoscopy Unit, the patient was placed in
131023 -        the left lateral decubitus position.
131024 -
131025 -        Oxygen at 2 liters per minuted by nasal cannula was
131026 -        administered.  Continuous oximetric and hemodynamic monitoring
131027 -        was initiated.
131029 -         ..
131030 -        Intravenous sedation was administered in divided doses.
131032 -         ..
131033 -        After a bite block was placed in the patient's mouth, an
131034 -        Olympus GIF-160 videogastroscope was advanced under direct
131035 -        vision to the esophagus; 200 ml of clear liquid was suctioned
131036 -        out of the esophagus.
131038 -         ..
131039 -        The endoscope was then advanced under direct vision into the
131040 -        descending duodenum.  Retroflexed views of the incisura, fundus
131041 -        and cardia were performed.
131043 -         ..
131044 -        Random biopsies were obtained of the gastric antrum and the
131045 -        body, labeled as Specimen A. ref SDS 0 VW49
131047 -         ..
131048 -        Directed biopsies obtained of the gastroesophageal junction at
131049 -        approximately 40 cm, labeled Specimen B. ref SDS 0 VW5L
131051 -         ..
131052 -        Random biopsies obtained of the esophageal body and labeled
131053 -        Speciment C. ref SDS 0 VW6R
131055 -         ..
131056 -        The stomach and esophagus were again decompressed and the
131057 -        gastro scope removed.
131058 -
131060 -     ..
131061 -    COMPLICATIONS:   None
131063 -     ..
131064 -    FINDING:
131065 -
131066 -        1.  Significantly dilated esophagus with 200 ml of residual
131067 -            liquid.
131068 -
131069 -        2.  Esophageal mucosa slightly friable and with adherent white
131070 -            curds.
131072 -             ..
131073 -        3.  Squamocolumnar junction coincident with gastro esophageal
131074 -            junction at approximately 40 cm.
131076 -             ..
131077 -        4.  Lower esophageal sphincter without evidence of mass effect.
131078 -            Resistance to the endoscope if higher than normal.
131080 -             ..
131081 -        5.  Mild gastric mucosal erythema.
131083 -             ..
131084 -        6.  Normal pylorus
131086 -             ..
131087 -        7.  Normal duodenum to D2
131088 -
131090 -     ..
131091 -    IMPRESSION;
131092 -
131093 -        1.  Dilated esophagus with residual liquid and increased
131094 -            resistance of the lower esophageal sphincter to endoscope
131095 -            pressure is all consistent with suspected diagnosis of
131096 -            achalasia.  There is no evidence of hiatal hernia or
131097 -            gastroesophageal reflux disease.
131099 -             ..
131100 -        2.  Stasis esophagitis due to retention of esophageal contents.
131102 -             ..
131103 -        3.  Gastritis, possibly due to Helicobacter pylori.
131104 -
131106 -     ..
131107 -    RECOMMENDATIONS:
131109 -             ..
131110 -        1.  Await the results of the biopsies to determine the presence
131111 -            or absence of malignancy and the presence or absence of
131112 -            Helicobacter pylori.
131114 -  ..
131115 - Biopsy dated 051213 seems to indicate no malignancy present,
131116 - ref SDS 0 714X, and no evidence of helicobacter pylori. ref SDS 0 454H
131118 -  ..
131119 - Doctor's Report continues...
131120 -
131121 -        2.  Assuming no evidence of malignancy, next step would be to
131122 -            perform esophadeal manometry.  This may be difficult
131123 -            without endoscopic-assisted passage of the manometry probe.
131124 -            Endoscopic ultrasound may also be considered if manometry
131125 -            is unsuccessful.
131127 -             ..
131128 -        3.  If all indicators are consistent with primary acalasia,
131129 -            proceed with pneumatic and balloon dilation with a 30-mm
131130 -            balloon.
131131 -
131133 -     ..
131134 -    DISPOSITION:
131135 -
131136 -        The patient was observed in the recovery room and then
131137 -        discharge to home with a companion.  He has given a copy of the
131138 -        photographs and the finds were explained to him before
131139 -        departure.
131140 -
131142 -     ..
131143 -    Dictated:        12/09/05
131144 -    Transcribed:     12/12/05
131145 -    Job Number:      2364527
131146 -    HGK/PSI
131147 -    $END
131148 -
131149 -
131150 -
131152 -  ..
131153 - Biopsy Report...
131154 -
131155 -    Surgical Pathology
131156 -
131157 -    Date Spec Taken:  Dec 09, 2005
131158 -    Date Spec rec'd:  Dec 12, 2005   10:59
131159 -    Date completed:  Dec 13, 2004
131160 -    Tathologist: Patricia L. Dalton, MD
131161 -    Resident:  Nalini MADIRAJU MD
131162 -    Accession #:  SP 05 5815
131163 -    Submitted by: Randall E. Lee MD
131165 -     ..
131166 -    Specimen:
131167 -
131168 -       A.   Stomach BX
131169 -       B.   GE Junction BX
131170 -       C.   Esophagus Body BX
131172 -     ..
131173 -    Brief Clinical History:
131174 -
131175 -       60 Y/O MAN WITH SUSPECTED PRIMARY ACHALASIA ? MALIGNANCY
131177 -     ..
131178 -    Preoperative Diagnosis:
131179 -
131180 -       ACHALASIA
131182 -     ..
131183 -    Operative Findings:
131184 -
131185 -       GASTRIC ERYTHEMA NORMAL GE JUNCTION ESOPHAGEAL BODY MUCOSA
131186 -       FRIABLE
131188 -     ..
131189 -    Postoperative Diagnosis:
131190 -
131191 -       GASTRITIS ACHALASIA WITH STASIS ESOPHAGITIS
131193 -     ..
131194 -    Gross description:
131195 -
131196 -       A.  Received in formalin, designated "stomach biopsy", and
131197 -           consists of multiple irregular fragments of gray-tan tissue
131198 -           measuring in aggregate 0.6 x 0.5 x 0.2 cm.  Tissue is
131199 -           totally submitted in one cassette.
131201 -            ..
131202 -       B.  Received in formalin, designated "ge junction biopsy", and
131203 -           consists of multiple irregular fragments of translucent to
131204 -           gray-tan tissue measuring in aggregate 0.6 x 0.5 x 0.2 cm.
131205 -           Tissue is totally submitted in one cassette
131207 -            ..
131208 -       C.  Received in formalin, designated "esophageal body", and
131209 -           consists of multiple irregular fragments of translucent to
131210 -           gray-tan tissue measuring in aggregate 0.6 x 0.5 x 0.2 cm.
131211 -           Tissue is totally submitted on one cassette. .
131212 -           (JT/12-12-04/dd)
131213 -
131215 -     ..
131216 -    Microscopic exam/diagnosis:  (Date Spec taken:  Dec 09, 2005)
131217 -
131218 -       A.  STOMACH, BIOPSY:
131219 -
131220 -           •  CHRONIC-ACTIVE GASTRITIS, ref SDS 0 OF6L
131222 -               ..
131223 -           •  NO HELICOBACTER PYLORI-LIKE ORGANISMS SEEN BY
131224 -              WARTHIN-STARRY STAIN.
131225 -
131227 -            ..
131228 -       B.  GASTROESOPHAGEAL JUNCTION, BIOPSY:
131229 -
131230 -           •  REFLUX ESOPHAGITIS WITH ULCERATION AND FOCAL CARDIAC-TYPE
131231 -              METAPLASIA
131233 -               ..
131234 -           •  NO INTESTINAL METAPLASIA (BARRETT'S ESOPHAGUS)
131236 -            ..
131237 -       C.  ESOPHAGUS BODY, BIOPSY:
131238 -
131239 -           •  REFLUX ESOPHAGITIS WITH ULCERATION
131240 -
131241 -           •  NO INTESTINAL METAPLASIA 9BARRETT;S ESOPHAGUS)
131242 -
131243 -
131244 -
131246 -  ..
131247 - Research on Gastritus....
131248 -
131249 -    Medicine, Instant Access to the Minds of Medicine
131250 -
131251 -        http://www.emedicine.com/med/topic852.htm
131252 -
131253 -    Author:
131254 -
131255 -        Antonia R Sepulveda, MD, PhD, Associate Professor, Department
131256 -        of Pathology, University of Pittsburgh
131258 -         ..
131259 -        Antonia R Sepulveda, MD, PhD, is a member of the following
131260 -        medical societies:  American Gastroenterological Association
131262 -         ..
131263 -    Coauthor(s):
131264 -
131265 -        Maria P Dore, MD, Assistant Professor, Department of Medicine,
131266 -        Institute of Internal Medicine, University of Sassari, Italy;
131267 -        Franco Bazzoli, MD, Professor, Department of Internal Medicine
131268 -        and Gastroenterology, University of Bologna, Italy
131270 -     ..
131271 -    Background:
131272 -
131273 -        Chronic gastritis, by definition, is a histopathological entity
131274 -        characterized by chronic inflammation of the stomach mucosa.
131275 -        Gastritises can be classified based on the underlying etiologic
131276 -        agent (eg, Helicobacter pylori, bile reflux, nonsteroidal
131277 -        anti-inflammatory drugs [NSAIDs], autoimmunity, allergic
131278 -        response) and the histopathological pattern, which may suggest
131279 -        the etiologic agent and clinical course (eg, H
131280 -        pylori-associated multifocal atrophic gastritis).  Other
131281 -        classifications are based on the endoscopic appearance of the
131282 -        gastric mucosa (eg, varioliform gastritis).  Although minimal
131283 -        inflammation is observed in some gastropathies, such as those
131284 -        associated with NSAID intake, these entities are discussed in
131285 -        this article because they are frequently included in the
131286 -        differential diagnosis of chronic gastritis.
131288 -         ..
131289 -        Chemical or reactive gastritis is caused by injury of the
131290 -        gastric mucosa by reflux of bile and pancreatic secretions into
131291 -        the stomach, but it can also be caused by exogenous substances,
131292 -        including NSAIDs, acetylsalicylic acid, chemotherapeutic
131293 -        agents, and alcohol.  These chemicals cause epithelial damage,
131294 -        erosions, and ulcers that are followed by regenerative
131295 -        hyperplasia, histologically detectable as foveolar hyperplasia
131296 -        and damage to capillaries, with mucosal edema, hemorrhage, and
131297 -        proliferation of smooth muscle in the lamina propria.
131298 -        Inflammation in these lesions caused by chemicals is minimal or
131299 -        lacking; therefore, the term gastropathy or chemical
131300 -        gastropathy is more appropriate to describe these lesions than
131301 -        is the term chemical or reactive gastritis as proposed by the
131302 -        updated Sydney classification of gastritis.  Importantly, mixed
131303 -        forms of gastropathy and other types of gastritis, especially H
131304 -        pylori gastritis, may coexist.
131306 -         ..
131307 -        No single classification of gastritis provides an entirely
131308 -        satisfactory description of all types of gastritis.  However,
131309 -        an etiological classification provides a direct target towards
131310 -        which therapy can be directed, and, for this reason,
131311 -        etiological classification is used in this article.
131313 -         ..
131314 -        In many instances, chronic gastritis is a relatively minor
131315 -        manifestation of diseases that predominantly manifest in other
131316 -        organs or manifest systemically, such as gastritis in
131317 -        individuals who are immunosuppressed.
131319 -         ..
131320 -        Helicobacter gastritis is a primary infection of the stomach
131321 -        and is the most frequent cause of chronic gastritis.  Cases of
131322 -        histologically documented chronic gastritis are diagnosed as
131323 -        chronic gastritis of undetermined etiology or gastritis of
131324 -        undetermined type when none of the findings reflects any of the
131325 -        described patterns of gastritis and a specific cause cannot be
131326 -        identified.
131328 -         ..
131329 -        Pathophysiology:
131331 -         ..
131332 -        The pathophysiology of chronic gastritis complicating a
131333 -        systemic disease, such as hepatic cirrhosis, uremia, or another
131334 -        infection, is described in the relevant disease articles.  The
131335 -        pathogenesis of the most common forms of gastritis is described
131336 -        as follows.
131338 -         ..
131339 -        H pylori-associated chronic gastritis
131340 -
131341 -            H pylori are gram-negative rods that have the ability to
131342 -            colonize and infect the stomach. The bacteria survive
131343 -            within the mucous layer that covers the gastric surface
131344 -            epithelium and the upper portions of the gastric foveolae.
131345 -            The infection usually is acquired during childhood.  Once
131346 -            the organism has been acquired, has passed through the
131347 -            mucous layer, and has become established at the luminal
131348 -            surface of the stomach, an intense inflammatory response of
131349 -            the underlying tissue develops.
131351 -             ..
131352 -            The presence of H pylori always is associated with tissue
131353 -            damage and the histological finding of both an active and
131354 -            chronic gastritis.  The host response to H pylori and
131355 -            bacterial products is composed of T- and B-cell
131356 -            lymphocytes, denoting chronic gastritis, followed by
131357 -            infiltration of the lamina propria and gastric epithelium
131358 -            by polymorphonuclear leukocytes that eventually phagocytize
131359 -            the bacteria.  The presence of polymorphonuclear leukocytes
131360 -            in the gastric mucosa is diagnostic of active gastritis.
131362 -             ..
131363 -            The interaction of H pylori with the surface mucosa results
131364 -            in the release of proinflammatory cytokine interleukin
131365 -            (IL)-8, which leads to recruitment of polymorphonuclear
131366 -            cells and may begin the entire inflammatory process.
131367 -            Gastric epithelial cells express class II molecules, which
131368 -            may increase the inflammatory response by presenting H
131369 -            pylori antigens, leading to further cytokine release and
131370 -            more inflammation.  High levels of cytokines, particularly
131371 -            tumor necrosis factor-a (TNF-a) and numerous ILs (eg, IL-6,
131372 -            IL-8, IL-10), are detected in the gastric mucosa of
131373 -            patients with H pylori gastritis.
131375 -             ..
131376 -            Leukotriene levels are also quite elevated, especially
131377 -            leukotriene B4, which is synthesized by host neutrophils
131378 -            and is cytotoxic to gastric epithelium.  This inflammatory
131379 -            response leads to functional changes in the stomach,
131380 -            depending on the areas of the stomach involved.  When
131381 -            inflammation affects the gastric corpus, parietal cells are
131382 -            inhibited, leading to reduced acid secretion.  Continued
131383 -            inflammation results in loss of parietal cells, and the
131384 -            reduction in acid secretion becomes permanent.
131385 -
131386 -
131387 -
131388 -
131389 -
131390 -
131391 -
131392 -
1314 -

SUBJECTS
Letter from VA Martinez Schedule Meeting 060131 1100 Sur Post Op Pla

1603 -
160401 -  ..
160402 - VA Letter Schedules Meeting in Martinez; Evidently Not Manometry Exam
160403 -
160404 - Follow up ref SDS 35 HA4Q, ref SDS 34 0001.
160405 -
160406 - Received another letter from the VA scheduling a meeting.  The letter
160407 - is dated 060109, and says in part...
160408 -
160409 -    This is a reminder of the followind clinic appointment(s):
160410 -
160411 -        Tuesday Jan 31, 2006 11:00 AM MTZ SUR POST OP PLAS(JAV) Clinic
160413 -     ..
160414 -    To cancel or reschedule this appointment, please call a Health
160415 -    Benefit Advisor in our Telephone Care Center at 1 800 382 8387,,,
160417 -  ..
160418 - The rest of the letter is standard language that does not present the
160419 - purpose of the meeting, who ordered the meeting, nor list the
160420 - attending physician, similar to the letter received on 051229.
160421 - ref SDS 34 0001
160422 -
160423 -     [On 060112 Kim clarifies that the VA changed the schedule of
160424 -     meeting with the plastic surgeon to review lipoma issue from
160425 -     060207 by moving it ahead to 060131. ref SDS 36 DP5O
160427 -  ..
160428 - Since this meeting is scheduled for Martinez, it does not seem likely
160429 - to be the esophugeal manometry examination, which the doctor has
160430 - ordered to take place in Sacramento, as shown in another letter
160431 - received today, per above. ref SDS 0 696L
160433 -  ..
160434 - Kim's letter on 060105 said that the meeting description does not
160435 - relate to the purpose nor the attending physician. ref SDS 35 HA4Q
160437 -  ..
160438 - Based on this record, nothing can be drawn from the VA's letter,
160439 - other than somone has scheduled a meeting for something.
160440 -
160441 -
160442 -
160443 -
160444 -
160446 -  ..
1605 -
1606 -
1607 - 2301
1608 -
160801 - Submitted an email to Kim requesting clarification of the meeting on
160802 - 060131, using the language submitted previously on 060105. ref SDS 35
160803 - GG9I
160804 -
160829 -    5.  Social security last 4... 0144
160856 -
160857 -
160858 -
160859 -
160860 -
160861 -
160862 -
160863 -
160864 -
160865 -
160866 -
160867 -
160868 -
1609 -