Esophageal biopsy report with a statement about dysplasia (present, absent, or indefinite, and if present, contains appropriate grading) (PATH)
CPT4 code
Esophageal Biopsy Report
Name of the Procedure:
Esophageal Biopsy, Esophagoscopy with Biopsy
Summary
An esophageal biopsy is a procedure where a small sample of tissue is taken from the esophagus to be examined under a microscope. This helps doctors diagnose various conditions affecting the esophagus, such as inflammation, infections, and cancers.
Purpose
The esophageal biopsy is used to identify abnormalities in the esophagus lining to diagnose diseases and conditions such as Barrett’s esophagus, esophagitis, and esophageal cancer. The primary goal is to detect changes that could indicate disease, including the presence of dysplasia (abnormal cells that could potentially become cancerous).
Indications
- Persistent acid reflux or gastroesophageal reflux disease (GERD)
- Difficulty swallowing (dysphagia)
- Unexplained chest pain
- Anemia with gastrointestinal tract bleeding
- Barrett’s esophagus surveillance
Preparation
- Fasting for at least 6-8 hours before the procedure.
- Discuss any medications with the physician; certain drugs may need to be paused.
- Undergo a pre-procedure diagnostic test, such as an endoscopy, to visualize the esophagus.
Procedure Description
- The patient will be administered sedation or anesthesia.
- An endoscope, a flexible tube with a camera, is inserted through the mouth and gently moved down the throat to the esophagus.
- Using small tools passed through the endoscope, the doctor takes a tissue sample from the esophagus lining.
- The collected tissue is preserved and sent to a pathology lab for analysis.
Duration
Approximately 15-30 minutes.
Setting
Typically performed in a hospital’s outpatient department, endoscopy suite, or a specialized surgical center.
Personnel
- Gastroenterologist or specialist performing the procedure.
- Endoscopy nurses assisting during the procedure.
- Anesthesiologist or sedation provider.
Risks and Complications
- Common: Sore throat, mild discomfort, and temporary bloating.
- Rare: Bleeding, infection, perforation of the esophagus, and reaction to sedation.
Benefits
- Accurate diagnosis of esophageal conditions.
- Early detection of precancerous changes (dysplasia) and appropriate grading if dysplasia is present.
- Informed decision-making for treatment plans.
Recovery
- Observation for a short duration post-procedure to ensure no immediate complications.
- Patients may experience mild throat discomfort, which usually resolves quickly.
- Avoid eating or drinking for a few hours post-procedure.
- Follow-up appointment to discuss biopsy results and next steps.
Alternatives
- Barium swallow study: A radiological exam involving contrast dye to visualize the esophagus.
- Non-invasive imaging tests, though less definitive than a biopsy.
Patient Experience
During the procedure, patients are usually sedated and should not feel pain, though a minor pressure sensation may be noticed. Post-procedure, some throat discomfort and bloating are common but manageable with over-the-counter pain relievers and rest.