Esophageal Dilation Procedure Note (Endoscopic)

(Use "Not documented" for missing clinically important fields and "Not applicable" for items that do not apply. Do not infer diameters, pressures, durations, or other procedural details not explicitly provided. Repeat sections labeled for multiple items as needed.)

Procedure Date and Time: [Date and time]

Location: [Unit, room, setting (outpatient / inpatient / ASC)]

Patient: [Patient identifier per local policy]

Endoscopist: [Name and credentials]

Procedure Performed: [Procedure name with technique and target location] (e.g., EGD with balloon dilation of distal esophageal stricture)

Indication: [Concise clinical reason] (e.g., solid food dysphagia due to known peptic stricture)

Pre-Procedure Assessment

• Prior dilations: [Dates, max diameter achieved, technique, complications / None]
• Relevant surgical/radiation history: [Prior esophageal surgery or radiation / None]
• Aspiration risk: [Risk factors and mitigation plan / Low risk]
• Antithrombotic status: [Agent(s), last dose, hold/bridge plan / None]
• Pertinent comorbidities: [Comorbidities impacting sedation or dilation risk]
• ASA class: [I / II / III / IV / V]
• NPO status: [Duration]
• Prior imaging/pathology: [Relevant findings informing stricture characteristics / None available]

Consent and Time-Out

Informed consent obtained after discussion of risks, benefits, and alternatives, including risk of perforation, bleeding, aspiration, post-procedure discomfort, and potential need for repeat sessions. Time-out performed confirming correct patient identity, procedure, allergies, anticoagulant status, and equipment readiness.

Sedation

Sedation type: [Moderate sedation / MAC / general anesthesia / none]

Provided by: [Endoscopy team / anesthesia service]

Medications: [Agents and doses] (If anesthesia-provided, state "See anesthesia record.")

Recovery status: [Status at procedure end] (e.g., returned to baseline, stable for transfer)

Procedure Technique

[Patient position]. [Endoscope type/model]. [Anatomic extent reached]. [Limitations encountered, if any]. [Quality of visualization].

Findings

• Esophagus: [Mucosal appearance, esophagitis grade if applicable, rings/furrows, retained food, other pathology] (Do not include stricture details here; use Stricture Characterization section.)
• Stomach: [Pertinent findings / Unremarkable]
• Duodenum: [Pertinent findings / Unremarkable]

Stricture Characterization

(Required when dilation is performed. Repeat this block for each stricture treated.)

Stricture #1

• Location: [Distance from incisors in cm], [proximal / mid / distal esophagus / GEJ / anastomosis]
• Morphology: [Estimated length in cm], [estimated pre-dilation luminal diameter in mm], [simple / complex (angulation, tortuosity, long segment, irregularity)]
• Traversability: Scope passed before dilation: [yes / no]. Guidewire required: [yes / no]. Smaller scope required: [yes / no].
• Suspected etiology: [Peptic / anastomotic / Schatzki ring / EoE / malignant / radiation / caustic / other]. Basis: [endoscopic appearance / prior pathology / clinical history].
• Mucosal findings at stricture: [Ulceration / inflammation / nodularity / friability / none]
• Pre-dilation biopsies: [Site(s) and rationale / Not obtained] (If malignancy suspected and biopsies not taken, document rationale.)

Dilation Log

(Add rows as needed. For balloon dilations, include inflation duration and waist observations when available.)

Target Site (Stricture #)	Device Type	Diameter(s) Used	Inflations/Passes per Diameter	Inflation Duration	Balloon Waist	Final Diameter Achieved
[Stricture #]	[TTS balloon / Savary / Maloney] [brand/model if known]	[Diameters in mm (balloon) or Fr (bougie)]	[Count per diameter step]	[Duration per inflation in seconds / N/A]	[Present / Effaced / N/A]	[Final diameter in mm or Fr]

• Endpoint criterion: [Easy scope passage / visual response / target diameter reached / symptom-based goal / other]
• Reason for stopping if target not reached: [Resistance / mucosal tear / concern for perforation / patient instability / N/A]
• Dilation strategy: [Rule of three followed / Deviated—rationale: (explain)]
• Fluoroscopy: [Used—rationale: (explain) / Not used] (If omitted in high-risk setting, document rationale.)

Post-Dilation Assessment

Re-inspection performed after final dilation. Mucosal disruption: [Location, depth (superficial mucosal rent / deeper laceration), bleeding (none / oozing / active), management if needed / None]. Perforation assessment: [No endoscopic evidence of perforation / Concerning findings identified—(describe findings and actions taken)].

Additional Interventions

(Include only if applicable; otherwise omit this section.)

• Biopsies: [Site(s), number, jar labels, rationale]
• Intralesional steroid injection: [Drug, total dose, concentration, injection sites/pattern]
• Hemostasis: [Modality, settings, outcome]
• Stent placement: [Type, size, position, fixation method, removal plan]

Specimens

[None / Site(s), quantity, labeling, and destination (pathology / microbiology / other)]

Complications

[No immediate complications / (Describe event, timing, interventions performed, response, and impact on disposition)]

Impression

• [Primary diagnosis with suspected etiology and certainty level]
• [Secondary findings, if any]
• [Procedural result summary] (e.g., dilated to 15 mm without complication)

Post-Procedure Plan

• Observation/disposition: [Discharge criteria met / Extended monitoring required—reason] [Disposition: home / observation / admission]
• Diet: [Clear liquids advancing to soft diet with timeline]
• Acid suppression: [PPI regimen / None indicated]
• Antithrombotic resumption: [Agent(s) and timing / N/A]
• Warning signs reviewed with patient: Chest/neck/abdominal pain, fever, dyspnea, hematemesis, inability to swallow liquids. [Contact instructions provided].
• Follow-up: [Clinic follow-up timing], [anticipated repeat dilation timing if applicable], [pathology result communication plan]