EGD Procedure Note (Variceal Screening/Banding)

Date: [Date]

Start Time: [Start time]

End Time: [End time] (Include only if captured)

Facility/Procedure Room: [Facility / room]

Endoscopist: [Name, credentials]

Anesthesia Provider: [Name, credentials] (Include only if applicable)

Referring Clinician: [Name, credentials]

Procedure Performed: [EGD (diagnostic) / EGD with EVL / EGD with additional therapeutic interventions: specify]

Pre-Procedure Diagnosis: [Diagnosis/indication]

Post-Procedure Diagnoses: [Diagnoses found and/or treated]

Indication and Portal Hypertension Context

[One-sentence indication: variceal screening / surveillance / post-EVL eradication session / secondary prophylaxis]

• Cirrhosis etiology: [viral / alcohol-associated / MASLD/NASH / cholestatic / autoimmune / other / unknown] (Include if known)
• Disease status: [compensated / decompensated]; (If decompensated: ascites [present / absent], hepatic encephalopathy [present / absent], prior variceal bleeding [yes with date / no])
• Prior variceal therapies: [None / EVL with approximate dates / sclerotherapy / TIPS / other: specify]
• NSBB therapy: [Not on NSBB (reason if known) / drug name, dose, tolerability]
• Case urgency: [Elective / Urgent for suspected or recent bleeding]
• Platelets: [value, date] (Include only if available; omit labs block entirely if unavailable)
• INR: [value, date] (Include only if available)
• MELD (or MELD-Na): [value, date] (Include only if available)

Pre-Procedure Assessment

Interval symptoms: [Brief summary of bleeding, dysphagia, chest pain, or other interval symptoms]

Allergies: [Allergy list and reactions] (Required)

Antithrombotic/antiplatelet status: [Drug(s), dose, last dose date/time, management plan: held / continued / bridged] (If history limited, state: Medication history confirmed to the extent possible)

Antibiotic prophylaxis: [Not indicated for elective screening/EVL / For suspected acute bleeding: agent, dose, route, duration]

NPO status: [Duration] (Optional per local practice)

Informed Consent

Consent obtained from [patient / authorized surrogate]. Capacity: [has capacity / lacks capacity with surrogate authorized]. The indication, expected benefits, alternatives including medical management, and material risks were discussed. Risks include bleeding, perforation, aspiration, sedation-related events, and missed lesions; for EVL specifically: post-banding ulcer, odynophagia, delayed bleeding, and rare stricture. Questions were answered and consent was given. (Required)

Time-Out Verification

Time-out performed immediately prior to the procedure verifying correct patient, correct procedure [EGD / EGD with EVL], allergies, and special concerns including antithrombotic status. (Required)

Sedation and Monitoring

• Sedation type: [Moderate sedation / Monitored anesthesia care (MAC) / General anesthesia] (Required)
• ASA physical status: [I / II / III / IV / V] [E if emergency]
• Medications administered: [Agent, dose, route for each medication; total doses] (Required)
• Monitoring modalities: [pulse oximetry / noninvasive blood pressure / ECG / capnography]
• Adverse sedation events: [None / specify] (Required)
• Moderate sedation intraservice time: [minutes] (Include only if moderate sedation per local billing rules)
• Independent trained observer present: [Yes: name/role / No] (Include only if required by local billing practice)

Procedure Details

• Patient position: [Left lateral decubitus / Supine / Other]
• Endoscope introduction: Endoscope introduced via the mouth under direct visualization.
• Extent of exam: Esophagus, stomach with retroflexion [performed / not performed: reason], duodenum to [bulb only / second portion (D2)] (If D2 not reached, state reason) (Required)
• Visualization quality: [Adequate / Limited: reason]
• Estimated blood loss: [None / Minimal / quantified in mL] (Required)
• Complications during procedure: [None / specify] (Required)
• Patient tolerance: [Good / Fair / Poor: reason if limited]

Findings

(Document only what was visualized; do not assume normal findings. State limitations explicitly when visualization incomplete.)

Esophagus

• Mucosal appearance: [Description of esophageal mucosa]
• Esophageal varices: [Present / Absent]

(If varices present, include the following)

• Size category: [Small / Large] or [Small / Medium / Large] (Per local standard)
• Location/extent: [Distance from incisors in cm and/or upper/mid/lower third(s)]
• Number of columns: [Number] (If used locally)
• Red wale marks or red spots: [Present / Absent]
• Active bleeding: [None / Oozing / Spurting / Adherent clot]
• Evidence of prior therapy: [Post-banding scars / Post-banding ulcers / None]
• Immediate post-banding appearance: [Bands in place; mucosal appearance at band sites] (If EVL performed)

Stomach

• Retroflexion and fundal visualization: [Complete / Limited: reason] (If not performed or fundus incompletely visualized, state: Gastric varices cannot be excluded)
• Gastric varices: [Present / Absent]; (If present: Sarin classification [GOV1 / GOV2 / IGV1 / IGV2], size, stigmata, active bleeding [None / Oozing / Spurting / Adherent clot])
• Portal hypertensive gastropathy: [Absent / Mild / Moderate / Severe]
• GAVE: [Present / Absent]
• Other gastric findings: [Erosions / Ulcers / Masses / Polyps / Retained blood or food / Other / None]

Duodenum

• Extent reached: [Bulb only / Second portion (D2)] (If not D2, state reason)
• Findings: [Duodenitis / Ulcers / Other lesions / Normal-appearing where visualized]

Interventions

(Include this section only if interventions were performed; omit entirely if none)

Endoscopic Variceal Ligation (EVL)

• Indication: [Primary prophylaxis / Secondary prophylaxis / Treatment during suspected bleeding]
• Target: [Esophageal varices / GOV1]
• Ligator/device type: [Device/manufacturer] (If tracked locally)
• Number of bands deployed: [Number] (Required)
• Locations banded: [Distances from incisors and/or anatomic descriptors]
• Immediate hemostasis status: [Not bleeding prior to banding / Bleeding controlled / Persistent bleeding]
• Complications during EVL: [None / specify: bleeding, mucosal tear, technical failure, other] (Required)
• If EVL not completed as planned: [Reason and what was achieved] (Include only if applicable)

Other Interventions

• Biopsies: [Site, number, purpose]
• Hemostatic therapy: [Method, site, outcome]
• Other procedures: [Specify]

Impression

• [Portal hypertension findings: esophageal varices (size, red signs present/absent, banded today yes/no with number); gastric varices (Sarin classification); PHG severity; GAVE status]
• [Other clinically important findings]
• [Visualization limitations, if any]

Recommendations

Post-Procedure Care

• [Diet advancement per protocol; if EVL performed: liquids progressing to soft foods for specified duration]
• No driving or major decisions for remainder of day after sedation.
• Return precautions: hematemesis, melena, severe chest pain, persistent dysphagia or odynophagia, fever, dyspnea.

Portal Hypertension Prophylaxis

• NSBB plan: [Start: drug, dose / Continue current regimen / Adjust: new drug or dose / Contraindicated or intolerant: reason]
• Acid suppression after EVL: [Short course PPI: agent, dose, duration] (If EVL performed; do not imply indefinite therapy without separate indication)

Follow-Up EGD Interval

(Select ONE pathway consistent with findings and NSBB status)

• No esophageal varices found: repeat EGD in approximately 2–3 years; earlier if decompensation occurs.
• Small varices without EVL: repeat EGD in approximately 1–2 years based on liver disease activity.
• EVL performed: repeat EVL session in 2–4 weeks until eradication, then surveillance every 3–6 months for first year post-eradication and every 6–12 months thereafter.

[Selected follow-up plan with specific interval and rationale]

Coordination

• Results communicated to [hepatology / referring provider: name, date/time].
• [Escalation plan if high-risk findings present: earlier hepatology follow-up, TIPS evaluation consideration] (Include only if applicable)

Complications and Disposition

• Immediate complications: [None / Bleeding / Perforation / Aspiration / Hypoxia / Arrhythmia / Other: specify] (Required)
• Post-procedure condition: [Stable / specify]
• Disposition: [Home / Observation / Admission: responsible service]
• Updates provided to: [Patient / Family / Referring provider]

Attestation

[Endoscopist signature, credentials] — [Date and time]