Anoscopy; with dilation (eg, balloon, guide wire, bougie)
CPT4 code
Name of the Procedure:
Anoscopy with dilation (e.g., balloon, guide wire, bougie)
Summary
Anoscopy with dilation is a medical procedure used to examine and widen the anal canal and lower rectum. It involves inserting a small tube (anoscope) and using instruments such as a balloon or bougie to stretch narrowed areas.
Purpose
To diagnose issues within the anal canal or rectum, such as strictures or blockages. The goal is to widen narrowed passages to improve symptoms like pain, bleeding, or difficulty with bowel movements.
Indications
- Anal strictures or narrowing
- Hemorrhoids requiring closer examination or treatment
- Chronic anal pain or bleeding
- Difficulty with bowel movements that suggest a blockage
Preparation
- Fast for several hours before the procedure
- Take bowel-cleansing agents if instructed
- Adjust medications as advised by the healthcare provider
- Inform the doctor of any allergies or underlying health conditions
Procedure Description
- The patient lies on their side or in a position for ease of access.
- Local anesthesia or mild sedation may be administered.
- An anoscope is gently inserted into the anal canal to visualize the area.
- Dilating instruments such as a balloon or bougie are introduced to widen the anal passage carefully.
- A guide wire may be used to assist with the insertion of dilating instruments.
- The area is gradually stretched to improve passage and relieve symptoms.
- The anoscope and dilating tools are removed, and the patient recovers from the anesthesia.
Duration
Typically takes 15 to 30 minutes.
Setting
Performed in an outpatient clinic, surgical center, or hospital.
Personnel
- Gastroenterologist or colorectal surgeon
- Nurses
- Anesthesiologist if sedation is used
Risks and Complications
- Minor bleeding
- Infection
- Pain or discomfort
- Rare risk of perforation or accidental injury to the rectum
Benefits
- Reduction in symptoms like pain, bleeding, or difficulty with bowel movements
- Improved anal canal function and patient comfort
Recovery
- Rest for the remainder of the day
- Follow specific post-procedure care instructions, such as stool softeners or pain relievers
- Avoid strenuous activities for a few days
- Follow-up appointment to assess healing and effectiveness
Alternatives
- Medication to manage symptoms
- Lifestyle and dietary changes
- Other non-surgical treatments like fiber supplements or sitz baths
- In severe cases, more invasive surgical procedures
Patient Experience
- Mild discomfort or pressure during the procedure
- Temporary soreness or minor bleeding afterward
- Pain management with over-the-counter medications if needed
- Generally, a quick recovery with minimal downtime