# Pouchoscopy



## chewri (Dec 12, 2013)

I could use some help cpt and Dx coding on the following op report: 

Indication: Fore Early Satiety, Abdominal Pain and history of Cohn's/ Ulcerative Colitis

HPI: This is a patient with a history of ulcerative colitis status post Proctocolectomy and a J-Pouch surgery, now with several weeks of early satiety and abdominal pain. The patient has been on three dose's of Remicade. 

Procedure: The patient was sedated by Anesthesia. Her pulse, vitals and oxygenation were monitored. A Colonoscope was inserted into the pouch and passed approximately to 25 to 30 cm. with visualization of the mucosa and then withdrawn.

Findings: Two to three small white ulcerations in the pouch, with random Biopsies taken. The ileum above appeared normal, with random biopsies taken.
Assessment: Likely minimal pouchitis.

 Thanks in advance for your help.


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## koatsj (Dec 16, 2013)

44386


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