Standardization and Coding of Gastrointestinal Endoscopy Reports

Gastrointestinal 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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