Standardization and Coding of Gastrointestinal Endoscopy Reports
2011
textabstractGastrointestinal endoscopy has developed rapidly in the last five decades. It started
in the sixties, when the first commercial model of the then recently invented fully
flexible fiberoptic gastroscope was developed. In the late sixties fiberoptic endoscopes
changed to forward viewing, with an open channel for air insufflation,
aspiration and a passage for accessories, especially biopsy instruments. In the
seventies with the introduction of a new side-viewing endoscope it became possible
to visualize the pancreatic duct and to perform endoscopic sphincterotomy, later
accompanied by stone extraction. Enteroscopy was first established in the mid
seventies and advanced into balloon-assisted enteroscopy, which enabled visualizing
and treating the whole small intestine in the new millennium. Endoscopic
ultrasound (EUS), developed in the 1980’s, has in recent years become tool for diagnosis
and therapy of a range of esophageal, gastric, hepatobiliary, pancreatic and
rectal disorders.
Nowadays these innovative techniques have evolved into a routine investigation
of the gastrointestinal tract. Patients with gastrointestinal complaints generally
undergo an endoscopic examination. In the Netherlands yearly approximately
400,000 examinations of the gastrointestinal tract are performed. With
these endoscopic studies abnormalities in esophagus, stomach, duodenum, colon,
small intestines and bile ducts are diagnosed and therapeutic interventions are
performed. The findings of these investigations have important implications for
patient management, for example for the selection of medical therapy for a gastric
ulcer or for the indication for a surgical intervention of a malignant process.
The endoscopist generates a report of the performed examination for the referring
physician. The reports range from short written or dictated reports to standardized
computer reports.
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