Not sure of the correct code(s) to use for the following operative report:
LA Grade A (one or more mucosal breaks less than 5 mm, not extending between tops of 2 mucosal folds) esophagitis
with no bleeding was found 32 to 37 cm from the incisors.
Diffuse mildly erythematous mucosa with no bleeding was found in the entire examined stomach. Biopsies were taken
with a cold forceps for histology.
The examined jejunum was normal.
Evidence of a Roux-en-Y gastrojejunostomy was found. This was traversed. The pouch-to-jejunum limb was
characterized by erythema, mild stenosis and visible sutures. A TTS dilator was passed through the scope. Dilation with a
[Size] anastomotic balloon dilator was successfully performed.
empiric 18-20 mm TTS dilation of efferrent anatomosis. nl app. afferent limb. no evidence of recurrent CA
Impression:
- LA Grade A reflux esophagitis.
- Gastric mucosal abnormality characterized by erythema. Biopsied.
- Normal examined jejunum.
- Roux-en-Y gastrojejunostomy.
Any help is appreciated.
LA Grade A (one or more mucosal breaks less than 5 mm, not extending between tops of 2 mucosal folds) esophagitis
with no bleeding was found 32 to 37 cm from the incisors.
Diffuse mildly erythematous mucosa with no bleeding was found in the entire examined stomach. Biopsies were taken
with a cold forceps for histology.
The examined jejunum was normal.
Evidence of a Roux-en-Y gastrojejunostomy was found. This was traversed. The pouch-to-jejunum limb was
characterized by erythema, mild stenosis and visible sutures. A TTS dilator was passed through the scope. Dilation with a
[Size] anastomotic balloon dilator was successfully performed.
empiric 18-20 mm TTS dilation of efferrent anatomosis. nl app. afferent limb. no evidence of recurrent CA
Impression:
- LA Grade A reflux esophagitis.
- Gastric mucosal abnormality characterized by erythema. Biopsied.
- Normal examined jejunum.
- Roux-en-Y gastrojejunostomy.
Any help is appreciated.