PROCEDURE NAME: Sphincterotomy and stone extraction INDICATION FOR PROCEDURE: Paroxysmal right upper quadrant pain associated with disturbed liver function that is post-cholecystectomy PROCEDURE DESCRIPTION: The Olympus Video side-viewing duodenoscope was atraumatically introduced into esophagus and advanced with slide-by technique into the stomach. The gastric mucosa was normal. The pyloric channel was normal and easily intubated. The first and second parts of the duodenum were visualized. The ampulla appeared normal. Initial cannulation with a precurved catheter revealed a normal pancreatic duct. A single injection was made into the pancreas. Repositioning was accomplished with the assistance of a straight 0.035 guidewire and free cannulation of the common duct was obtained, revealing a large multifaceted free floating stone within the common bile duct. The intrahepatic biliary system appeared normal. The extrahepatic biliary system appeared dilated. An exchange was made with a 20-mm sphincterotome and a sphinctPROCEDURE NAME: Sphincterotomy and stone extraction INDICATION FOR PROCEDURE: Paroxysmal right upper quadrant pain associated with disturbed liver function that is post-cholecystectomy PROCEDURE DESCRIPTION: The Olympus Video side-viewing duodenoscope was atraumatically introduced into esophagus and advanced with slide-by technique into the stomach. The gastric mucosa was normal. The pyloric channel was normal and easily intubated. The first and second parts of the duodenum were visualized. The ampulla appeared normal. Initial cannulation with a precurved catheter revealed a normal pancreatic duct. A single injection was made into the pancreas. Repositioning was accomplished with the assistance of a straight 0.035 guidewire and free cannulation of the common duct was obtained, revealing a large multifaceted free floating stone within the common bile duct. The intrahepatic biliary system appeared normal. The extrahepatic biliary system appeared dilated. An exchange was made with a 20-mm sphincterotome and a sphincterotomy was performed with perfect hemostasis. The duct was then swept with a 15-mm stone extraction balloon and the stone was pulled into the duodenal lumen and removed. The duct was “swept” 2 more times with negative results. The procedure was terminated with the patient in satisfactory condition and she was returned to the recovery area for observation. ASSESSMENT: Choledocholithiasis associated with recurring obstruction and biliary colic in a post-cholecystectomy patient. Assign ICD-10-PCS code(s) to the following case studies:
PROCEDURE NAME: Sphincterotomy and stone extraction INDICATION FOR PROCEDURE:…
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