EGD with botox injection

PREPROCEDURE DIAGNOSIS: Dysphagia and probable dysmotility of the esophagus.

POSTPROCEDURE DIAGNOSIS: Dysphagia and probable dysmotility of the esophagus.

PROCEDURE PERFORMED: Esophagogastroduodenoscopy with Botox injection.

DESCRIPTION OF PROCEDURE: The patient is a 68-year-old female who was evaluated for conscious sedation and was found to be a candidate under my supervision. During the procedure the patient received Hurricaine for local anesthesia of the pharynx, fentanyl 50 mcg and Versed 3 mg. During the procedure the patient received Botox 100 units.

The patient was kept in the left lateral decubitus. An Olympus videopanendoscope was advanced without difficulty into the esophagus, which was mildly tortuous but no ulcers or masses were seen. No stricture. The GE junction was identified at 38 cm from the incisors. The panendoscope was advanced into the stomach. The fundus, body and antrum looked normal. No ulcers or masses were seen. The pylorus was identified and did not look deformed. The panendoscope was advanced into the duodenum. The mucosa looked normal. No ulcers or masses were seen. We withdrew the panendoscope into the distal esophagus. At approximately 2 cm above the GE junction we started injecting 1 mL of normal saline with 10 units of Botox. We went up into the esophagus. At every centimeter we injected 10 units for a total of 100 units. The patient tolerated the procedure.

PLAN: Will follow the patient in the office in a couple of weeks.

codes: 
Code: 
43236
Code Type: 
CPT
Code: 
45.13
Code Type: 
ICD-9
Code: 
99.29
Code Type: 
ICD-9
Code: 
0DJ48ZZ
Code Type: 
ICD-10
Code: 
3E0G8GC
Code Type: 
ICD-10