Operative report EGD

Operative report 1

Indication: Persistent epigastric pain, gastroesophageal reflux disease (GERD), and dyspepsia refractory to medical therapy.

Anesthesia: Monitored Anesthesia Care

Complication: None

Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After I obtained informed consent, the endoscope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.

The EGD was introduced through the mouth and advanced under direct visualization through the esophagus into the stomach and subsequently into the second portion of the duodenum. The examination was performed without difficulty. The patient tolerated the procedure well.

Findings:

The esophagus was normal in caliber with no evidence of stricture, mass, ulceration, or varices. Mild erythema of the distal esophageal mucosa was noted, consistent with mild reflux esophagitis. The gastroesophageal junction was otherwise unremarkable.

The gastric fundus, body, and cardia appeared normal. Mild erythematous mucosa was present within the gastric antrum, consistent with mild gastritis. No gastric ulcer, erosion, active bleeding, or mass lesion was identified. Retroflexed examination of the gastric fundus and cardia was unremarkable.

The pylorus was patent without evidence of stenosis.

The duodenal bulb and second portion of the duodenum appeared normal without ulceration, inflammation, bleeding, or mucosal abnormality.

No biopsies or therapeutic interventions were performed.

Impression:

• Mild distal reflux esophagitis.

• Mild antral gastritis.

• Normal gastric fundus and body.

• Normal duodenal bulb and second portion of the duodenum.

• No ulcers, masses, active bleeding, or other significant abnormalities.

• Examination otherwise unremarkable.

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• 43235 : EGD diagnostic

Operative report 2

Indication: Gastric polyps identified on prior upper endoscopy requiring endoscopic removal for histopathologic evaluation.

Anesthesia: Monitored Anesthesia Care

Complication: None

Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After I obtained informed consent, the EGD was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.

The EGD was introduced through the mouth and advanced under direct visualization through the esophagus into the stomach and subsequently into the third portion of the duodenum. The examination was performed without difficulty. The patient tolerated the procedure well.

Findings:

The esophagus appeared normal without evidence of esophagitis, stricture, ulceration, or varices. The gastroesophageal junction was unremarkable.

Within the gastric body, a 4 mm sessile polyp was identified. The lesion was completely removed using cold biopsy forceps. Complete resection and retrieval were achieved. There was minimal self-limited oozing without active bleeding.

Within the gastric antrum, an 8 mm sessile polyp was identified. The lesion was completely removed using a cold snare technique. Complete resection and retrieval were achieved. The polypectomy site was carefully inspected and demonstrated excellent hemostasis without active bleeding or residual polyp tissue.

The remainder of the gastric mucosa, including the fundus, cardia, and incisura, appeared normal. Retroflexion demonstrated no additional abnormalities.

The pylorus was patent. The duodenal bulb and second portion of the duodenum appeared normal without ulceration, inflammation, or mass lesion.

The resected polyps were retrieved and submitted separately for histopathologic examination.

Impression:

• 4 mm sessile polyp in the gastric body, completely removed with cold biopsy forceps.

• 8 mm sessile polyp in the gastric antrum, completely removed with cold snare.

• Complete retrieval of both specimens.

• Normal esophagus and duodenum.

• Examination otherwise unremarkable.

See Pathology here

SURGICAL PATHOLOGY REPORT

Specimen A: Gastric body polyp, cold forceps polypectomy

Gross Description:Received in formalin labeled "Gastric Body Polyp" is a single tan-pink soft tissue fragment measuring 0.4 × 0.3 × 0.2 cm. The specimen is submitted entirely in one cassette.

Microscopic Description:Sections demonstrate gastric oxyntic mucosa containing a fundic gland polyp characterized by cystically dilated fundic glands lined by flattened parietal and chief cells. No epithelial dysplasia or malignancy is identified.

Final Diagnosis:

• Fundic gland polyp.

• Negative for dysplasia.

• Negative for malignancy.

Specimen B: Gastric antral polyp, cold snare polypectomy

Gross Description:Received in formalin labeled "Gastric Antral Polyp" is a tan-pink polypoid soft tissue fragment measuring 0.8 × 0.6 × 0.3 cm. The specimen is submitted entirely in one cassette.

Microscopic Description:Sections demonstrate a hyperplastic gastric polyp composed of elongated, tortuous foveolar glands with edematous and inflamed lamina propria. No intestinal metaplasia, dysplasia, or invasive carcinoma is identified.

Final Diagnosis:

• Hyperplastic gastric polyp.

• Negative for dysplasia.

• Negative for malignancy.

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• 43251 – EGD with snare polypectomy (cold snare removal of the 8 mm gastric polyp).

• 43239-59 – EGD with biopsy (cold forceps removal of the 4 mm gastric polyp).

  
  

Operative report 3

Indication: Gastric polyps identified during surveillance upper endoscopy requiring endoscopic removal for definitive histopathologic evaluation.

Anesthesia: Monitored Anesthesia Care

Complication: Immediate post-polypectomy bleeding successfully controlled endoscopically.

Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After I obtained informed consent, the EGD was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.

The EGD was introduced through the mouth and advanced under direct visualization through the esophagus into the stomach and subsequently into the second portion of the duodenum. The examination was performed without difficulty. The patient tolerated the procedure well.

Findings:

The esophagus appeared normal without evidence of esophagitis, ulceration, stricture, or varices.

Within the gastric body, a 10 mm sessile polyp was identified. The lesion was completely resected using a hot snare polypectomy technique with electrocautery. The specimen was successfully retrieved for histopathologic examination.

Immediately following polypectomy, active arterial oozing was noted from the polypectomy base. The polypectomy site was carefully irrigated to identify the bleeding source. Endoscopic hemostasis was achieved by deployment of two through-the-scope hemostatic clips directly across the bleeding vessel and polypectomy defect. Bleeding ceased immediately. The site was observed for several minutes, demonstrating durable hemostasis without recurrent bleeding.

A second 6 mm sessile polyp was identified within the gastric antrum. This lesion was also completely removed using a hot snare polypectomy technique. The specimen was retrieved intact. The post-polypectomy site demonstrated no active bleeding.

The remainder of the gastric mucosa, including the fundus, cardia, and incisura, appeared normal. Retroflexion revealed no additional abnormalities.

The pylorus was widely patent. The duodenal bulb and second portion of the duodenum were normal without ulceration, inflammation, or mass lesion.

Both polypectomy specimens were retrieved and submitted separately for histopathologic examination.

Impression:

• 10 mm sessile gastric body polyp successfully removed by hot snare polypectomy.

• Immediate post-polypectomy bleeding from the gastric body polypectomy site successfully controlled with placement of two endoscopic hemostatic clips.

• 6 mm sessile gastric antral polyp successfully removed by hot snare polypectomy without bleeding.

• Complete retrieval of both polyp specimens.

• Normal esophagus and duodenum.

• Examination otherwise unremarkable.

See Pathology here

SURGICAL PATHOLOGY REPORT

Specimen A: Gastric body polyp, hot snare polypectomy

Gross Description:Received in formalin labeled "Gastric Body Polyp" is a tan-pink polypoid soft tissue fragment measuring 1.0 × 0.8 × 0.4 cm. The specimen is serially sectioned and submitted entirely in one cassette.

Microscopic Description:Sections demonstrate a hyperplastic gastric polyp composed of elongated and cystically dilated foveolar glands with edematous stroma and chronic inflammatory infiltrates. No high-grade dysplasia or invasive carcinoma is identified. The cauterized resection margin is free of polyp.

Final Diagnosis:

• Hyperplastic gastric polyp.

• Negative for dysplasia.

• Negative for malignancy.

• Resection margin free of polyp.

Specimen B: Gastric antral polyp, hot snare polypectomy

Gross Description:Received in formalin labeled "Gastric Antral Polyp" is a tan-pink polypoid tissue fragment measuring 0.6 × 0.5 × 0.3 cm. The specimen is submitted entirely in one cassette.

Microscopic Description:Sections demonstrate a fundic gland polyp with cystically dilated oxyntic glands lined by parietal and chief cells. No epithelial dysplasia or malignancy is identified. The cauterized resection margin is uninvolved.

Final Diagnosis:

• Fundic gland polyp.

• Negative for dysplasia.

• Negative for malignancy.

• Resection margin free of polyp.

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43251 – EGD with snare polypectomy.

Coding Note: In this scenario, the bleeding is an expected consequence of the hot snare polypectomy and was controlled during the same procedure. Under CPT/NCCI guidance, 43255 is generally not separately reportable when hemostasis is performed for bleeding that results directly from the endoscopic procedure itself (i.e., post-polypectomy bleeding). Only 43251 would typically be reported. 43255 is generally reserved for treatment of pre-existing gastrointestinal bleeding (e.g., bleeding ulcer, Dieulafoy lesion, AVM, or actively bleeding lesion unrelated to the endoscopic intervention).

Operative report 4

Indication: Progressive solid food dysphagia secondary to symptomatic Schatzki ring.

Anesthesia: Monitored Anesthesia Care

Complication: None

Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After I obtained informed consent, the EGD was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.

The EGD was introduced through the mouth and advanced under direct visualization through the esophagus into the stomach and subsequently into the second portion of the duodenum. The examination was performed without difficulty. The patient tolerated the diagnostic portion of the procedure well.

Findings:

The proximal and mid esophagus appeared normal. A circumferential Schatzki ring was identified at the gastroesophageal junction producing mild luminal narrowing. The endoscope traversed the narrowing with mild resistance. No evidence of ulceration, mass lesion, or Barrett's esophagus was identified.

The stomach, including the fundus, body, antrum, and cardia, appeared normal. Retroflexion demonstrated no additional abnormalities.

The pylorus was patent. The duodenal bulb and second portion of the duodenum appeared normal.

A Savary guidewire was advanced through the working channel of the EGD under direct visualization and positioned within the gastric antrum. The EGD was carefully withdrawn while maintaining guidewire position.

Sequential Savary-Gilliard dilators were then advanced over the guidewire under fluoroscopic guidance. Dilation was performed progressively using 45 French, 48 French, and finally 51 French Savary dilators without significant resistance. Each dilator was advanced across the Schatzki ring and withdrawn in a controlled fashion.

Following dilation, the EGD was reintroduced to reassess the esophagus. The Schatzki ring demonstrated an adequate mucosal disruption with improved luminal diameter. There was a small superficial mucosal tear at the dilation site without active bleeding or evidence of perforation. The remainder of the esophagus was unremarkable.

The stomach and duodenum were again inspected and remained normal. The procedure was completed without immediate complication.

Impression:

• Symptomatic Schatzki ring at the gastroesophageal junction.

• Successful esophageal dilation using sequential Savary-Gilliard dilators (45 Fr, 48 Fr, and 51 Fr) over a guidewire.

• Small expected superficial post-dilation mucosal tear without active bleeding or perforation.

• Normal stomach and duodenum.

• Examination otherwise unremarkable.

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43248 – EGD with insertion of guidewire followed by passage of dilator(s) over the guidewire.

Operative report 5

Indication: Progressive dysphagia secondary to benign distal esophageal stricture refractory to medical therapy.

Anesthesia: Monitored Anesthesia Care

Complication: None

Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After I obtained informed consent, the EGD was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.

The EGD was introduced through the mouth and advanced under direct visualization through the esophagus into the stomach and subsequently into the second portion of the duodenum. The examination was performed without difficulty. The patient tolerated the diagnostic portion of the procedure well.

Findings:

The proximal and mid esophagus appeared normal. A benign concentric distal esophageal stricture was identified approximately 38 cm from the incisors, measuring approximately 10 mm in luminal diameter and extending for approximately 1.5 cm. The endoscope traversed the stricture with mild resistance. No evidence of ulceration, mass lesion, or Barrett's esophagus was identified.

The stomach, including the fundus, body, antrum, and cardia, appeared normal. Retroflexion revealed no hiatal hernia or additional abnormalities.

The pylorus was patent. The duodenal bulb and second portion of the duodenum were normal.

A through-the-scope (TTS) esophageal balloon dilator was advanced across the distal esophageal stricture under direct endoscopic visualization. The balloon was sequentially inflated across the stricture to 30 mm, followed by 31.5 mm and a maximum diameter of 33 mm, with each inflation maintained for approximately 60 seconds. The balloon was then completely deflated and removed.

The EGD was reintroduced for reassessment. The stricture demonstrated satisfactory disruption with a significantly improved luminal diameter. A small superficial mucosal tear was present at the dilation site, representing an expected post-dilation finding. There was no active bleeding or evidence of perforation.

The stomach and duodenum were again inspected and remained unremarkable.

The procedure was completed without immediate complications.

Impression:

• Benign distal esophageal stricture causing dysphagia.

• Successful endoscopic balloon dilation of the esophagus using a through-the-scope balloon to a maximum diameter of 33 mm (>30 mm).

• Expected superficial mucosal disruption without active bleeding or perforation.

• Normal stomach and duodenum.

• Examination otherwise unremarkable.

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43249 – EGD with transendoscopic balloon dilation of the esophagus 30 mm diameter or greater.

Operative report 6

Indication: Symptomatic benign gastric outlet obstruction secondary to pyloric stricture with persistent nausea, vomiting, early satiety, and inability to tolerate solid food.

Anesthesia: Monitored Anesthesia Care

Complication: None

Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After I obtained informed consent, the EGD was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.

The EGD was introduced through the mouth and advanced under direct visualization through the esophagus into the stomach. The esophagus appeared normal without evidence of esophagitis, stricture, or mass lesion.

Within the stomach, a moderate amount of retained fluid was suctioned to improve visualization. The gastric body and fundus were unremarkable. A short benign-appearing pyloric stricture was identified at the gastric outlet measuring approximately 8 mm in diameter. The surrounding mucosa demonstrated mild chronic inflammatory changes without ulceration or evidence of malignancy. The endoscope could not initially be advanced through the narrowed pyloric channel.

A through-the-scope (TTS) controlled radial expansion (CRE) balloon dilator was advanced across the pyloric stricture under direct endoscopic visualization. Sequential balloon dilation was performed to 10 mm, 12 mm, and finally 15 mm, with each inflation maintained for approximately 60 seconds. The balloon was then deflated and removed.

Following dilation, the EGD was advanced through the pylorus without significant resistance into the duodenal bulb and second portion of the duodenum. The duodenal mucosa appeared normal without ulceration, inflammation, or mass lesion.

The EGD was withdrawn while carefully re-examining the dilation site. The pyloric channel demonstrated a significantly improved luminal diameter with a small superficial mucosal tear, an expected finding following dilation. There was no active bleeding or evidence of perforation.

The patient tolerated the procedure well without immediate complications.

Findings:

• Benign pyloric (gastric outlet) stricture causing gastric outlet obstruction.

• Successful balloon dilation of the pyloric stricture to 15 mm using a through-the-scope balloon.

• Expected superficial mucosal disruption without active bleeding or perforation.

• Normal duodenal bulb and second portion of the duodenum.

• Examination otherwise unremarkable.

Impression:

• Benign pyloric stricture with gastric outlet obstruction.

• Successful endoscopic balloon dilation of the gastric stricture.

• Improved pyloric patency following dilation.

• No immediate procedural complications.

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43245 – EGD with transendoscopic balloon dilation of gastric or duodenal stricture.

Operative report 7

Indication: Large gastric adenomatous lesion with high-grade dysplasia identified on prior biopsy, concerning for early gastric neoplasia. Endoscopic mucosal resection (EMR) was recommended for complete excision and definitive histopathologic evaluation.

Anesthesia: Monitored Anesthesia Care

Complication: None

Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A normal, healthy patient. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After I obtained informed consent, the EGD was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.

The EGD was introduced through the mouth and advanced under direct visualization through the esophagus into the stomach and subsequently into the second portion of the duodenum. The examination was performed without difficulty. The patient tolerated the procedure well.

Findings:

The esophagus appeared normal without evidence of esophagitis, Barrett's esophagus, or stricture.

Within the lesser curvature of the gastric antrum, a 25 mm slightly elevated superficial mucosal lesion (Paris classification 0-IIa) was identified. The lesion was carefully inspected using high-definition white-light and narrow-band imaging. The margins were well defined without endoscopic features suggestive of deep submucosal invasion.

The borders of the lesion were circumferentially marked using the tip of a coagulation device.

A submucosal lifting solution consisting of normal saline, dilute epinephrine, and methylene blue was injected beneath the lesion, producing an adequate and sustained mucosal lift.

Following satisfactory elevation, a 20 mm stiff braided snare was positioned around the lesion. Endoscopic mucosal resection (EMR) was performed using electrocautery. Due to the size of the lesion, the resection was completed in piecemeal fashion with complete removal of all visible adenomatous tissue.

The resection bed was carefully inspected. No residual visible lesion remained. Mild oozing from the mucosal defect was successfully treated using soft coagulation. The margins and base of the EMR site were further treated with argon plasma coagulation (APC) to reduce the risk of residual adenomatous tissue.

The resected tissue fragments were completely retrieved using a Roth retrieval net and submitted for histopathologic examination.

The post-EMR mucosal defect measured approximately 30 mm. Three through-the-scope endoscopic clips were placed to partially approximate the mucosal defect and reduce the risk of delayed bleeding.

The remainder of the stomach appeared normal. The pylorus was patent. The duodenal bulb and second portion of the duodenum were normal.

The procedure was completed without immediate complications.

Impression:

• 25 mm superficial gastric adenomatous lesion involving the lesser curvature of the gastric antrum.

• Successful endoscopic mucosal resection following submucosal lifting.

• Complete endoscopic removal of all visible lesion.

• Mild intraprocedural bleeding successfully treated with coagulation.

• EMR defect partially closed with three endoscopic clips.

• Specimen completely retrieved for histopathologic examination.

• Examination otherwise unremarkable.

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43254 – EGD with endoscopic mucosal resection (EMR).

Coding Note: The submucosal injection, snare resection, retrieval of the specimen, and clip closure of the EMR defect are considered integral components of the EMR procedure and are not separately reported.

Operative report 8

Indication: Cirrhosis with portal hypertension and large esophageal varices requiring endoscopic variceal ligation for primary prevention of variceal hemorrhage.

Anesthesia: Monitored Anesthesia Care

Complication: None

Procedure: The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior anticoagulants: The patient has taken no previous anticoagulant or antiplatelet agents. ASA Grade Assessment: A patient with severe systemic disease. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After I obtained informed consent, the EGD was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.

The EGD was introduced through the mouth and advanced under direct visualization through the esophagus into the stomach and subsequently into the second portion of the duodenum. The examination was performed without difficulty. The patient tolerated the procedure well.

Findings:

The proximal esophagus appeared normal.

Within the distal esophagus, three columns of Grade III esophageal varices were identified extending approximately 8 cm proximal to the gastroesophageal junction. Several varices demonstrated red wale markings, consistent with a high risk of future bleeding. There was no active hemorrhage at the time of examination.

The stomach demonstrated mild portal hypertensive gastropathy involving the gastric body and fundus. No gastric varices or active bleeding were identified.

The pylorus was patent. The duodenal bulb and second portion of the duodenum appeared normal.

The endoscope was withdrawn, and a multiple-band ligation device was attached to its distal tip. The EGD was reintroduced into the distal esophagus.

Beginning at the gastroesophageal junction and proceeding in a spiral fashion proximally, six endoscopic bands were sequentially deployed over the largest variceal columns until complete ligation of all accessible high-risk varices was achieved. The varices demonstrated satisfactory suction into the ligator cap before each band deployment, resulting in complete variceal occlusion.

Following completion of band ligation, the treated area was carefully inspected. All bands remained securely positioned with complete collapse of the ligated varices. There was no active bleeding, mucosal injury, or evidence of perforation.

The stomach was decompressed, and the EGD was withdrawn. The patient tolerated the procedure well without immediate complications.

Impression:

• Three columns of Grade III distal esophageal varices with red wale signs.

• Successful endoscopic variceal ligation with deployment of six bands.

• Mild portal hypertensive gastropathy.

• No gastric varices.

• No active gastrointestinal bleeding.

• Examination otherwise unremarkable.

Check your answer

43244 – EGD with band ligation of esophageal and/or gastric varices.