What does my endoscopy report mean!?
At the end of your procedure, before you go home, you will receive a report, along with key images of the test you have had done. This report is designed to communicate findings to other doctors including your GP, but is also important for you to understand.
This information is designed to give you a small insight into what some of the medical terminology means. It is by no means an extensive or exhaustive list, but covers in my experience, many of the questions that patients have.
If you have any questions regarding your report, we can make time to carefully go through things to answer any outstanding issues or concerns.
Procedure:
“Gastroscopy/UGI Endoscopy” – camera study down the food tube into the stomach and small bowel (looks at over 1 metre of the tract).
“Colonoscopy/LGI Endoscopy” – camera study into the large intestine. Looks at approximately 1.5 metres of large intestine and 5-10cm of the last part of the small intestine.
“Indication” – a short summary as to why you are having the test.
“Sedation” – what medication was given to you.
- “Xylocaine throat spray” – this is the spray that numbs the throat.
- “Fentanyl” - This is primarily to avoid and treat pain.
- “Midazolam” – This is given to make you drowsy, less aware, and often affects memory so you may not remember the test!
“Patient tolerance” – sometimes a small note is made of how you responded to the test. Often it is written that you “tolerated well,” but occasionally it may be “tolerated poorly.” This is no reflection of you of course – everyone is different. You may not even remember anything of this at all. This comment is generally made to alert us in the future should the test need to be done again so we can make the experience better.
“Procedure” - This describes what we have done and performed. It often states how far the camera was advanced, and what was seen.
Key words:
- “Biopsy” – a small sample of tissue taken for further analysis under the microscope. The sample is usually on 1-3mm in size.
- Examination with “white light” and “NBI.” This describes the different light sources that can be used to examine the lining of the gastrointestinal tract to detect small and subtle abnormalities, or better define areas of abnormality (see video). NBI stands for “narrow band imaging” and is a type of blue light, whereby blood vessels become more prominent and this can help interpretation.
Gastroscopy reports:
- "Z Line": This is the line that can be seen that indicates a change of cells from the oesophagus (gullet) to the stomach. This is often examined carefully and measured (a distance may be written such as 40cm – which is the distance from your teeth to this line). This is where abnormal cells may grow such as in Barrett’s oesophagus – so this is usually noted down.
- “Oesophagitis” – inflammation of the food tube. This generally occurs at the bottom, around the “Z-line”
- “Gastritis” – inflammation of the stomach
- “Ulcer” – this is a defined area of damage in the lining. Often it is scooped out and, if already healing, may be covered in a white film as the lining attempts to repair itself.
- “CLO test”: this is a type of test taken with a biopsy to check for Helicobacter pylori – a bacteria which can cause inflammation, pain and bloating in the stomach. This may take 24-72 hours to be available.
- “Mucosa” – this means tissue lining the wall of the gastrointestinal tract.
- “Atrophic” – this means that the lining of the wall is flattened and thin, and can indicate previous infection with Helicobacter pylori.
- “Biopsied for histology” – this means small samples of tissue were taken to analyse down the microscope. This may take 5 days or longer to review with a result. Just because something is biopsied, does not mean there was a large or worrying abnormality.
Colonoscopy reports:
- “Bowel preparation score” – this is a record of how clear the preparation was.
- “PR exam” – this stands for “per-rectal” examination and is a gloved finger examination of the anus and rectum. This is important to do to check there is nothing abnormal that can be felt, and this area is sometimes difficult to examine with the camera itself.
- “Polyp” – this is warty outgrowth from the lining of the bowel. See additional patient information for further discussion.
- “Paris/Kudo/NICE” – these are different classification systems that we use to describe what the polyp looks like.
- “Sessile polyp” – this means the polyp is flat
- “Pedunculated polyp” – this means the polyp is on a stalk – a bit like a mushroom
- “semi-pedunculated” – halfway between the two!
- “Size of polyp” – this is always recorded. This is important for a variety of reasons. For certain types of polyps, as a general rule, the larger the polyp, the more likely it is to go on the turn, or already be on the turn to bowel cancer. Polyps more than 10mm (1cm) are generally deemed to be on the larger size.
- “Cold snare” – this describes how the polyp was removed – without using electrocautery.
- “Hot snare” - this describes how the polyp was removed – with using electrocautery to help cut it off with additional heat. This is sometimes needed if the polyp is larger with a higher risk of bleeding
- “EMR” – this stands for endoscopic mucosal resection. This is a technique where fluid is injected into the tissue below the below, allowing the margins of the polyp to be better seen, or lift the polyp away from underlying tissue so it is safer to remove. Generally, this is used for larger polyps, although this is not always the case.
- “Paris/Kudo/NICE” – these are different classification systems that we use to describe what the polyp looks like.
- “Terminal ileum/distal ileum” – this is the last part of the small intestine, where it joins to the large intestine. This is a ‘landmark’ that indicates that the doctor has definitively passed the camera all the way to the end of the large bowel.
- “Diverticulosis” – these are outpouchings in the lining of the bowel. See additional patient information for further discussion.
- “Haemorrhoids” – these are engorged blood vessels in the rectum. See additional patient information for further discussion.
- “Retroflexion” – this is the term used when the camera is turned around in a hook shape to look backwards toward itself.
"Histology" – this means examination under the microscope. “Await histology” means we will be waiting for the pathologist (specialist doctor who does these examinations) to provide a final report and opinion.