Sections in this upper GI endoscopy report template
- Indication & relevant history
- Preparation, consent & mucosal visibility
- Technique, extent examined & inspection time
- Oesophagus
- Normal: The oesophagus is normal in calibre with smooth, pink mucosa. No varices, oesophagitis or mass is seen. The gastro-oesophageal junction is at the expected anatomical level.
- Oesophagitis: The distal oesophagus shows linear mucosal erythema and superficial erosions consistent with reflux oesophagitis.
- Barrett's: Salmon-coloured columnar mucosa extends proximally from the gastro-oesophageal junction, suspicious for Barrett's oesophagus.
- Varices: Grade I–II non-bleeding oesophageal varices are seen along the distal longitudinal folds.
- Stomach
- Normal: The stomach expands well with insufflation. Fundus, body and antral mucosa appear healthy. No ulcer, polyp or active bleeding is seen.
- Gastritis: Patchy antral erythema, congestion and subepithelial haemorrhage are consistent with mild antral gastritis.
- Gastric ulcer: A well-defined ulcer is visible in the antrum with regular borders and a fibrinous base.
- Hiatal hernia: Retroflexion demonstrates a small sliding hiatal hernia with laxity of the diaphragmatic pinch.
- Duodenum
- Normal: The duodenal bulb and second part appear normal. Villous architecture and vascularity are preserved.
- Duodenitis: The duodenal bulb shows mucosal congestion and erythema consistent with active duodenitis.
- Duodenal ulcer: A small active ulcer is seen on the anterior wall of the duodenal bulb with surrounding oedema.
- Interventions, specimens & complications
- Impression & follow-up plan
- Normal study: Normal upper GI endoscopy.
Quality-focused documentation outline. Confirm indication, preparation, inspection extent and time, landmark photos, interventions, complications and the final plan for the procedure actually performed.
Quality details recorded
- Inspection time (minutes)
- Mucosal visibility score / scale used
Photo documentation checklist
- Upper oesophagus
- Gastro-oesophageal junction
- Gastric fundus / cardia
- Gastric body
- Gastric antrum
- Duodenal bulb
- Second part of duodenum
- Every abnormal finding
How to use this template in MedPrax Report
- Create a free account and choose Upper GI endoscopy as the procedure.
- Add the patient details, or pick a returning patient to reuse them.
- Capture frames from a scope connected to your laptop, or upload images, and choose up to ten for the report.
- Tap the common findings, then edit, type or dictate your own wording.
- Review the report and download the signed PDF. Later corrections are added as amendments.
Frequently asked questions
What should an upper GI endoscopy report include?
The indication, consent and sedation, mucosal visibility, extent examined and inspection time, findings for the oesophagus, stomach and duodenum, any interventions or specimens, complications, and the impression with a follow-up plan. Landmark photographs support each finding.
Is this the same as an OGD or EGD report?
Yes. Upper GI endoscopy, oesophagogastroduodenoscopy (OGD) and esophagogastroduodenoscopy (EGD) describe the same examination, and this template covers all three.
Can I change the wording of the sample findings?
Every finding is editable. The sample text is a starting point that you confirm or rewrite for the patient in front of you.
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