# and this one ICD 10 only



## AgnieszkaMarek (Nov 16, 2018)

Preoperative diagnosis: Abdominal pain in the setting of prior cholecystectomy
Findings: The esophagus was successfully intubated under direct vision without detailed examination of the pharynx, larynx, and associated structures, and upper GI tract. One stent originating in the biliary tree was emerging from the major papilla. A biliary sphincterotomy had been performed. The sphincterotomy appeared open. One stent was removed from the biliary tree using a snare. A short 0.035 inch Soft Jagwire was passed into the biliary tree. The 12 mm to 15 mm balloon was passed over the guidewire and the bile duct was then deeply cannulated. Contrast was injected. I personally interpreted the bile duct images. There was brisk flow of contrast through the ducts. Image quality was excellent. Contrast extended to the hepatic ducts. A cholecystectomy had been performed. The main bile duct was mildly dilated and diffusely dilated. The largest diameter was 11mm. The lower third of the main bile duct contained one mobile filling defect thought to be a stone, which was small. The biliary tree was swept with a 12 mm balloon and 15 mm balloon starting at the lower third of the main duct and bifurcation. A small amount of biliary debris was swept from the duct. Nothing remained on final occlusion cholangiogram and balloon sweep.

Estimated Blood Loss: Estimated blood loss: none.
Impression: - One stent from the biliary tree was seen in the major papilla and was removed.
- Prior biliary endoscopic sphincterotomy appeared open.
- The entire main bile duct was mildly dilated.
- Choledocholithiasis was found. Complete removal was accomplished by balloon extraction.


Diagnosis: 
Calculus of bile duct without cholecystitis or obstruction


----------

