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CPC sample question # 14

Indications: This is a third follow-up dilation for this patient. He had a pyloric channel uncer, which has been slow to heal and has hadsubsequent pyloric stenosis and obstruction. This is a repeat evaluation and dilation.

Procedure: With the patient in the left lateral decubitus position, the endoscope was inserted into the proximal esophagus and advanced to the Z-line. The esophageal mucosa was unremarkable. The stomach was entered, revealing normal gastric mucosa. Mild erythema was seen in the antrum. The pyloric channel was again widened. However, the ulcer as previously seen was well healed with a scar. The pyloric stenosis was still present, somewhat obstructing the pyloric channel. With some probing, the 11 mm endoscope was introduced into the second portion of the duodenum revealing normal mucosa. Marked deformity and scarring was seen in the proximal bulb. A 15 mm ballon was placed across the stricture and dilated to maximum pressure and withdrawn.

There was minimal postprocedural bleeding. Much easier access in to the duodenum was accomplished after the dilation. Follow-up biopsies were also taken to evaluate Helicobacter noted on a previous examination. The patient tolerated the procedure and was discharged in good condition.

Impression: Pyloric stenosis secondary to healed pyloric channel ulcer dilated as described.

Plan: Check on biopsy, continue prilosec for at least another 30 days. At that time, a repeat endoscopy and final dilation will be accomplised. He will almost certainly need continous H2 blocker therapy to avoid recurrence of the ulcer.

a.    43235, 43245-59
b.    43245
c.    43245, 43239-59
d.    43249


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