Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
CPT4 code
Name of the Procedure:
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps. (Common name: Flexible Colonoscopy with Hot Biopsy)
Summary
This procedure involves the insertion of a flexible endoscope into the colon to inspect the internal lining. Any tumors, polyps, or other abnormalities are identified and removed using hot biopsy forceps.
Purpose
The procedure addresses the detection and removal of abnormal growths in the colon, such as polyps or tumors, to prevent cancer or understand symptoms like bleeding or unexplained changes in bowel habits. The goal is to diagnose and treat potentially harmful lesions in the colon.
Indications
- Rectal bleeding
- Chronic diarrhea or constipation
- Unexplained weight loss
- Positive fecal occult blood test
- Personal or family history of colorectal cancer or polyps
Preparation
- Fasting: Patients are usually required to refrain from eating and drinking (except clear liquids) for at least 24 hours before the procedure.
- Bowel Prep: A bowel-cleansing substance is taken to clear out the colon.
- Medication Adjustments: Certain medications, especially blood thinners, may need to be paused or adjusted.
- Diagnostic Tests: Evaluation of medical history and possible blood tests.
Procedure Description
- Sedation or anesthesia is administered to keep the patient comfortable.
- A flexible endoscope is gently guided through the rectum into the colon.
- The colon lining is examined in detail.
- Hot biopsy forceps are used to cauterize and remove any abnormal growths.
- Removed tissue samples may be sent to a lab for further analysis.
Duration
The procedure typically takes between 30 to 60 minutes.
Setting
The procedure is commonly performed in a hospital outpatient unit, endoscopy center, or specialized surgical center.
Personnel
- Gastroenterologist or trained endoscopist
- Registered nurse
- Anesthesiologist or nurse anesthetist (if sedation is used)
- Endoscopy technician
Risks and Complications
- Common: Mild bloating or cramping, minor bleeding at the biopsy site.
- Rare: Perforation of the colon, significant bleeding requiring further treatment, infections, adverse reactions to sedation.
Benefits
- Early detection and treatment of potentially cancerous polyps.
- Relief from symptoms such as bleeding or pain.
- Improved digestive health and peace of mind. Benefits are often realized shortly after the procedure, following tissue analysis.
Recovery
- Post-procedure observation until sedation wears off.
- Instructions: Avoid driving, heavy lifting, or consuming alcohol for 24 hours.
- Normal activities can typically be resumed within a day or two.
- Follow-up: Consultation regarding biopsy results and further care plans.
Alternatives
- Sigmoidoscopy: Limited to examining the rectum and lower colon.
- CT Colonography: Non-invasive but less comprehensive.
- Fecal Tests: Non-invasive but less definitive. Each alternative has its own set of pros and cons, with varying degrees of accuracy and invasiveness.
Patient Experience
During the procedure, patients will be under sedation and should not feel pain. Minor discomfort or bloating may occur afterward. Pain management includes over-the-counter medications, and the healthcare team will ensure the patient's comfort throughout the process.