Could I get help coding the following procedure and dx's.
Indications for colonoscopy: This is a 52 year old female who is status post a very low anterior resection, essentially a coloanal anastomosis with diverting loop ileostomy. She has completed the chemotherapy that is planned and at this point is being considered for ostomy reversal. When I attempted to examine her anastomosis and pouch in the office she was too uncomfortable to tolerate it. She was therefore brought to the endoscopy Suite for EUA.
Procedure:
Today the patient was brought to the endoscopy suite and sedated per anesthesia protocol. The pediatric colonoscope was inserted. Her anastomosis was encountered just a couple of CM up and it is severely strictured. Photographs were taken. It did not look ischemic. She underwent progressive balloon dilatation from 8mm-10mm, up to 12mm. At this point I was able to pass the scope through. The remaining portion of her pouch appears viable. I did not want to dilate any further secondary to the severe stricture and I would prefer to do this sequentially. We will therefore bring her back in a couple of weeks for sequential dilatation.
Thank you for your help
Indications for colonoscopy: This is a 52 year old female who is status post a very low anterior resection, essentially a coloanal anastomosis with diverting loop ileostomy. She has completed the chemotherapy that is planned and at this point is being considered for ostomy reversal. When I attempted to examine her anastomosis and pouch in the office she was too uncomfortable to tolerate it. She was therefore brought to the endoscopy Suite for EUA.
Procedure:
Today the patient was brought to the endoscopy suite and sedated per anesthesia protocol. The pediatric colonoscope was inserted. Her anastomosis was encountered just a couple of CM up and it is severely strictured. Photographs were taken. It did not look ischemic. She underwent progressive balloon dilatation from 8mm-10mm, up to 12mm. At this point I was able to pass the scope through. The remaining portion of her pouch appears viable. I did not want to dilate any further secondary to the severe stricture and I would prefer to do this sequentially. We will therefore bring her back in a couple of weeks for sequential dilatation.
Thank you for your help