suela923@aol.com
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We are wondering if we can bill for a duodenography, 74260? We billed 47500, 74320, 47511, 75982.
Percutaneous transhepatic cholangiogram with placement of a biliary drainage catheter
History: Endometrial cancer with large peripancreatic mass. Patient presents with jaundice and impending bowel obstruction.
Technique: A timeout was performed. Under sterile technique, local anesthesia, and conscious sedation a 21-gauge needle was inserted using fluoroscopic guidance into the liver through an intercostal right-sided approach. After several passes, a peripheral right-sided duct was engaged and the biliary tree was opacified with injected contrast.. It was not possible to pass a guidewire fluoroscopically from this small duct into the central ductal system. Therefore, a second 21-gauge needle was used to puncture a more central right sided duct, which was accomplished without difficulty. A guidewire was then advanced into the common bile duct and a 6-French catheter was advanced over the guidewire into the biliary tree. Opacification of the biliary tree shows marked dilatation of the intrahepatic ducts. There is striking dilatation of the upper common bile duct. The common duct is occluded approximately 6 cm above the ampulla. Utilizing a variety of guidewires and catheters, a guidewire was successfully advanced across the obstructed portion of the bile duct and into the duodenum using fluoroscopic guidance.. Multiple images were obtained of the duodenum showing marked compression of the duodenum both proximal and distal to the ampulla. The duodenal narrowing is particularly severe distal to the ampulla. Contrast is seen passing through this region into the small bowel however. Contrast also refluxes up into the duodenal bulb.
Amplatz wire was again reinserted and positioned in the distal duodenum. The tract was dilated and an 8-French biliary catheter was inserted with its distal loop in the duodenum and its most proximal sidehole in the dilated common bile duct. This will be allowed to drain externally overnight as the bile is very viscus and dark. It was not possible to completely coil the catheter in the duodenum due to severe compression.
IMPRESSION:
1. Marked biliary ductal dilatation. The point of obstruction appears to lie in the upper common bile duct with a long segment which is severely compressed and narrowed all the way to the ampulla. The length of obstruction is at least 6 cm. The descending duodenum, inferior genu, and entire transverse duodenum are severely compressed and narrowed. The narrowing is particular severe in the transverse duodenum.
2. Successful placement of a biliary drainage catheter into the biliary tree, across the obstruction, and into the duodenum. This will be allowed to drain externally. Attempt can then be made for internal drainage. Indwelling metal stents can be placed depending on consultation with gastroenterology and plans for duodenal stent placement.
Thanks!
Sue
Percutaneous transhepatic cholangiogram with placement of a biliary drainage catheter
History: Endometrial cancer with large peripancreatic mass. Patient presents with jaundice and impending bowel obstruction.
Technique: A timeout was performed. Under sterile technique, local anesthesia, and conscious sedation a 21-gauge needle was inserted using fluoroscopic guidance into the liver through an intercostal right-sided approach. After several passes, a peripheral right-sided duct was engaged and the biliary tree was opacified with injected contrast.. It was not possible to pass a guidewire fluoroscopically from this small duct into the central ductal system. Therefore, a second 21-gauge needle was used to puncture a more central right sided duct, which was accomplished without difficulty. A guidewire was then advanced into the common bile duct and a 6-French catheter was advanced over the guidewire into the biliary tree. Opacification of the biliary tree shows marked dilatation of the intrahepatic ducts. There is striking dilatation of the upper common bile duct. The common duct is occluded approximately 6 cm above the ampulla. Utilizing a variety of guidewires and catheters, a guidewire was successfully advanced across the obstructed portion of the bile duct and into the duodenum using fluoroscopic guidance.. Multiple images were obtained of the duodenum showing marked compression of the duodenum both proximal and distal to the ampulla. The duodenal narrowing is particularly severe distal to the ampulla. Contrast is seen passing through this region into the small bowel however. Contrast also refluxes up into the duodenal bulb.
Amplatz wire was again reinserted and positioned in the distal duodenum. The tract was dilated and an 8-French biliary catheter was inserted with its distal loop in the duodenum and its most proximal sidehole in the dilated common bile duct. This will be allowed to drain externally overnight as the bile is very viscus and dark. It was not possible to completely coil the catheter in the duodenum due to severe compression.
IMPRESSION:
1. Marked biliary ductal dilatation. The point of obstruction appears to lie in the upper common bile duct with a long segment which is severely compressed and narrowed all the way to the ampulla. The length of obstruction is at least 6 cm. The descending duodenum, inferior genu, and entire transverse duodenum are severely compressed and narrowed. The narrowing is particular severe in the transverse duodenum.
2. Successful placement of a biliary drainage catheter into the biliary tree, across the obstruction, and into the duodenum. This will be allowed to drain externally. Attempt can then be made for internal drainage. Indwelling metal stents can be placed depending on consultation with gastroenterology and plans for duodenal stent placement.
Thanks!
Sue