4.0 STANDARD ENDOSCOPIC TERMS
4.1 Scope
4.1.1 General considerations
The terms have been organized by examination type (Upper GI Endoscopy, Colonoscopy and ERCP), with an additional complementary list of Therapeutic Procedures that might be performed. Within each examination type, the terms have been grouped under the various headings used within the OMED terminology for each organ examined. There are a few exceptions to terms included under these headings. Most notable is the inclusion of post-surgical findings under the "Lumen" heading. Whilst this is not a "lesion", it is apparent that the changes visible after a previous surgical procedure will be seen while examining the lumen of a particular organ (e.g. an ileo-colonic anastomosis while examining the colon or a Billroth II anastomosis when within the stomach) and should be recorded at this time.
The list of terms displayed for any location vary with the organ being examined. For example, the term "esophagitis" only appears in the esophageal section, while the term "spot" is found in the stomach and colon but not in the esophagus. Thus, the list of terms is varied where a particular term is felt to be inappropriate for a particular location.
Terms used to describe functional changes, such as contractility and elasticity of the wall, increased or decreased peristalsis, functional narrowing or extrinsic distortion, have been excluded from the minimal terminology as they were considered to be too subjective and imprecise to aid making a diagnosis. In addition, these terms were too open to misinterpretation for use in any multicentre studies.
4.1.2 Attributes values and locations.
When appropriate, each term has attached to it qualifying attributes
which provide additional detail. The attributes are a list of descriptive terms such as
size, number, extent, etc… for which there are a series of values appropriate to that
term. For example, the attributes for a duodenal ulcer include : size (in millimeters);
shape (superficial, cratered or linear) ; bleeding (yes, no or "stigmata of recent
bleeding", defined by Forrest's criteria). Every lesion described is placed in its
location by the use of a list of sites relevant to the organ being examined.
4.2 List of terms for esophago-gastro-duodenoscopy.
The following terms shall be used to describe observations made during examination of the upper gastrointestinal tract.
4.2.1 List of terms for the esophagus
The following terms shall be used to describe observations made during examination of the esophagus.
Table 6. Terms for the esophagus.
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTE VALUES |
SITES |
| Normal | Normal | Z line | Distance in cm | cm from incisors |
| Lumen | ||||
| Dilated | Site(s) | |||
| Stenosis | Appearance | Extrinsic | cm from incisors | |
| Benign intrinsic | ||||
| Malignant intrinsic | ||||
| Length (cm) | ||||
| Traversed | Yes | |||
| After dilatation | ||||
| No | ||||
| Extrinsic Impression | Size | Small | Site(s) | |
| Large | ||||
| Web | Site(s) | |||
| Ring (iincludes Schatzki Ring) | Site(s) | |||
| Hiatus Hernia | Size / Volume | Small | ||
| Medium | ||||
| Large | ||||
| Site of Z-line | cm from incisors | |||
| Site of Hiatal Narrowing | cm from incisors | |||
| Lower Esophageal Sphincter | Tone | Gaping | ||
| Hypertonic | ||||
| Evidence of previous surgery | Anastomosis | Esophago-jejunal | cm from teeth | |
| Esophago-gastric | ||||
| Esophago-colonic | ||||
| Suture material visible | Yes | Site(s) | ||
| No | Site(s) | |||
| Contents | ||||
| Foreign Body | Type | Specify… | Site(s) | |
| Blood | Kind of blood | Red | Site(s) | |
| Clot | ||||
| Hematin (Altered Blood) | ||||
| Food | Site(s) | |||
| Bile | Site(s) | |||
| Stent | Type | Specify | Site(s) | |
| Band | Number | Site(s) | ||
| Position | Free | |||
| Attached | ||||
| Mucosa | ||||
| Erythematous (Hyperemic) | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Esophagitis | Grade | Grade I | Upper border (cm from incisors) | |
| Grade II | ||||
| Grade III | ||||
| Grade IV | ||||
| Bleeding | Yes | |||
| No | ||||
| Barrett's Esophagus | Distance: | Z- line | cm from incisors | |
| Distance: | Upper end of Gastric Folds | cm from incisors | ||
| Candidiasis | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Mucosal sclerosis | Type | Spontaneous | Site(s) | |
| Post-therapy | ||||
| Extent | Localised | |||
| Patchy | ||||
| Diffuse | Site(s) | |||
| Flat lesions | ||||
| Ectopic gastric mucosa | Number | Single | Site(s) | |
| Multiple | ||||
| Plaque | Number | Single | Site(s) | |
| Multiple | ||||
| Protruding lesions | ||||
| Nodule | Number | Single | Site(s) | |
| Few | ||||
| Many | ||||
| Extent | Localized | |||
| Patchy | ||||
| Diffuse | ||||
| Tumor/Mass | Size | Small | Site(s) | |
| Medium | ||||
| Large | ||||
| Type | Submucosal | |||
| Fungating | ||||
| Ulcerated | ||||
| Circumferential | Yes | |||
| No | ||||
| Obstructing | Partial | |||
| Complete | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Varices | Grade | Grade I | Site(s) | |
| Grade II | ||||
| Grade III | ||||
| Size | Estimated width in mm | |||
| Upper limit | cm from incisors | |||
| Bleeding | Yes: Spurting | |||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of recent bleeding | Yes | |||
| No | ||||
| Red signs | Yes | |||
| No | ||||
| Site(s) | ||||
| Excavated lesions | ||||
| Mallory-Weiss tear | Bleeding | Yes: Spurting | ||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Erosion | Number | Single | Site(s) | |
| Few | ||||
| Many | ||||
| Ulcer | Number | Site(s) | ||
| Size (mm) | Site (cm from incisor) | |||
| Bleeding | Yes: Spurting | |||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of recent bleeding | Yes | |||
| No | ||||
| Scar | Site(s) | |||
| Diverticulum | Site(s) | |||
| Fistula | Site(s) | |||
| Other | Specify | Site(s) |
4.2.2 List of terms for the stomach
The following terms shall be used to describe observations made during examination of the stomach.
Table 7. Terms for stomach
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTE VALUES |
SITES |
| Normal | Normal | Site(s) | ||
| Lumen | ||||
| Stenosis | Appearance | Extrinsic | Site(s) | |
| Benign intrinsic | ||||
| Malignant intrinsic | ||||
| Traversed | Yes | |||
| No | ||||
| Deformity | Site(s) | |||
| Extrinsic Impression | Site(s) | |||
| Evidence of previous surgery | Anastomosis | Billroth I | ||
| Billroth II | ||||
| Gastroenterostomy | ||||
| Pyloroplasty | ||||
| Anti-reflux surgery | ||||
| Banded gastroplasty | ||||
| Suture material visible | Yes | Site(s) | ||
| No | ||||
| Gastrostomy | Type | Surgical | Site(s) | |
| Endoscopic (PEG) | Site(s) | |||
| Contents | ||||
| Blood | Kind of blood | Red | Site(s) | |
| Clot | ||||
| Hematin (altered blood) | ||||
| Food (residue) | Type | Specify if Bezoar present | Site(s) | |
| Fluid | Appearance | Clear | Site(s) | |
| Excessive | ||||
| Bilious | ||||
| Foreign Body | Type | Specify | Site(s) | |
| Stent | Type | Specify | Site(s) | |
| Mucosa | ||||
| Erythematous (Hyperemic) | Extent | Localised | Site(s) | |
| Patchy | ||||
| Striped | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | ||||
| Congested (Edematous) | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Granular | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Friable | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes: Spontaneous | |||
| Yes: Contact bleeding | ||||
| No | ||||
| Nodular | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Atrophic | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Hemorrhagic | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Petechia | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localised | |||
| Diffuse | ||||
| Site(s) | ||||
| Flat Lesions | ||||
| Spot (area) | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localised | |||
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| Subepithelial | ||||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Dieulafoy lesion | Bleeding | Yes: Spurting | Site(s) | |
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Angioectasia | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localised | |||
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Site(s) | ||||
| Protruding lesions | ||||
| Enlarged folds | Extent | Localised | Site(s) | |
| Diffuse | ||||
| Type | Thick | Site(s) | ||
| Giant | ||||
| Papule (Nodule) | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Polyp | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Pedicle | Sessile | |||
| Pedunculated | ||||
| Size | Small (< 5 mm) | |||
| Medium (5-20 mm) | ||||
| Large (> 20 mm) | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Tumor/Mass7 | Size | Small | Site(s) | |
| Medium | ||||
| Large | ||||
| diameter in mm | ||||
| Type | Submucosal | |||
| Fungating | ||||
| Ulcerated | ||||
| Infiltrative | ||||
| Circumferential | Yes | |||
| No | ||||
| Bleeding | Yes: Spurting | |||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Varices | Bleeding | Yes: Spurting | Site(s) | |
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Suture granuloma | Site(s) | |||
| Excavated lesions | ||||
| Erosion | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localised | |||
| Dispersed | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Ulcer | Number | Site(s) | ||
| Size | Largest diameter in mm | |||
| Shape | Superficial | |||
| Cratered | ||||
| Linear | ||||
| Bleeding | Yes: Spurting | |||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Visible Vessel | |||
| Clot | ||||
| Pigmented Material | ||||
| No Stigmata | ||||
| Scar | Number | Single | Site(s) | |
| Multiple | ||||
| Diverticulum | Site(s) |
4.2.3 List of terms for the duodenum and jejunum
The following terms shall be used to describe observations made during examination of the duodenum.
Table 8. Terms for duodenum
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTE VALUES |
SITES |
| Normal | Normal | Site(s) | ||
| Lumen | ||||
| Stenosis | Appearance | Extrinsic | Site(s) | |
| Benign intrinsic | ||||
| Malignant intrinsic | ||||
| Traversed | Yes | |||
| No | ||||
| Deformity | Appearance | Extrinsic | Site(s) | |
| Post-ulcer | ||||
| Evidence of previous surgery | Specify | Site(s) | ||
| Suture Material Visible | Yes | Site(s) | ||
| No | ||||
| Contents | ||||
| Blood | Kind of blood | Red | Site(s) | |
| Clot | ||||
| Hematin (altered blood) | ||||
| Parasites | Site(s) | |||
| Foreign Body | Site(s) | |||
| Stent | Type | Specify | Site(s) | |
| Mucosa | ||||
| Erythematous (Hyperemic) | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Congested (Edematous) | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Granular | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Friable | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes: Spontaneous | |||
| Yes: Contact bleeding | ||||
| No | ||||
| Nodular | Extent | Localised | Site(s) | |
| Diffuse | ||||
| Atrophic | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Hemorrhagic | Extent | Localised | Site(s) | |
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Flat Lesions | ||||
| Spot (area) | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localized | |||
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Subepithelial | ||||
| Hematin stained (altered blood) | ||||
| Angioectasia | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localised | |||
| Patchy | ||||
| Diffused | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Protruding lesions | ||||
| Polyp(s) | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Size | Small (< 5 mm) | |||
| Medium (5-20 mm) | ||||
| Large (> 20 mm) | ||||
| Pedicle | Sessile | |||
| Pedunculated | ||||
| Bleeding | Yes | |||
| No | ||||
| Tumor/Mass | Size | Small | Site(s) | |
| Medium | ||||
| Large | ||||
| diameter in mm | ||||
| Type | Submucosal | |||
| Fungating | ||||
| Ulcerated | ||||
| Infiltrative | ||||
| Frond-like/Villous | ||||
| Bleeding | Yes: Spurting | |||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Excavated lesions | ||||
| Erosion | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localised | |||
| Segmental | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Ulcer | Number | Site(s) | ||
| Size | Largest diameter in mm | |||
| Shape | Superficial | |||
| Cratered | ||||
| Linear | ||||
| Bleeding | Yes: Spurting | |||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Visible vessel | |||
| Clot | ||||
| Pigmented material | ||||
| No stigmata | ||||
| Scar | Number | Single | Site(s) | |
| Multiple | ||||
| Diverticulum | Opening | Large | Sites | |
| Small | ||||
| Fistula | Site(s) |
4.3 List of terms for colonoscopy.
The following terms shall be used to describe observations made during examination of the lower gastrointestinal tract.
Table 9. Terms for colon
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTES VALUES |
SITES |
| Normal | Normal | Site(s) | ||
| Lumen | ||||
| Dilated | Site(s) | |||
| Stenosis | Appearance | Extrinsic | Site(s) | |
| Benign intrinsic | ||||
| Malignant intrinsic | ||||
| Length (cm) | ||||
| Traversed | Yes/No | |||
| Evidence of previous surgery | Type | Colo-colonic anastomosis Ileo-colonic anastomosis Colo-anal anastomosis Ileo-anal anastomosis Colostomy |
Site(s) | |
| Suture Material Visible | Specify | |||
| Site(s) | ||||
| Contents | ||||
| Blood | Kind of blood | Red | Site(s) | |
| Clot | ||||
| Hematin (Altered blood) | ||||
| Foreign body | Site(s) | |||
| Parasites | Site(s) | |||
| Exudate | Site(s) | |||
| Stool | Site(s) | |||
| Stent | Type | Specify | Site(s) | |
| Mucosa | ||||
| Vascular pattern | Appearance | Normal | Site(s) | |
| Increased | ||||
| Decreased | ||||
| Extent | Localised | |||
| Segmental | ||||
| Diffuse | ||||
| Erythematous (Hyperemic) | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Congested (Edematous) | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Granular | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Friable | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Bleeding | Yes: Spontaneous | |||
| Yes: Contact bleeding | ||||
| No | ||||
| Ulcerated mucosa | Continuity | Discontinuous | Site(s) | |
| Continuous | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Petechiae | Number | Few | Site(s) | |
| Multiple | ||||
| Pseudomembrane | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Melanosis | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Flat lesions | ||||
| Angioectasia | Number | Single | ||
| Few | ||||
| Multiple | ||||
| Size | Small | |||
| Medium | ||||
| Large | ||||
| Extent | Localised | |||
| Patchy | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Protruding lesions | ||||
| Polyp(s) | Number | if less than 5, specify if more than 5: Many Multiple |
Site(s) | |
| Extent | Localised | |||
| Segmental | ||||
| Diffuse | ||||
| Size | in mm | |||
| Pedicle | Sessile | |||
| Pedunculated | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | ||||
| Pseudopolyps | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Lipoma | Size | Small | Site(s) | |
| Medium | ||||
| Large | ||||
| Diameter | mm | |||
| Tumor/Mass7 | Size | Small | Site(s) | |
| Medium | ||||
| Large | ||||
| diameter in mm | ||||
| Length | in cm | |||
| Type | Submucosal | |||
| Fungating | ||||
| Ulcerated | ||||
| Infiltrative | ||||
| Frond-like/Villous | ||||
| Obstructing | Partial | |||
| Complete | ||||
| Circumferential | Yes | |||
| No | ||||
| Bleeding | Yes: Spurting | |||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Hypertrophy Anal Papillae | ||||
| Hemorrhoids | Bleeding | Yes | ||
| No | ||||
| Suture granuloma | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Condylomas | ||||
| Excavated lesions | ||||
| Erosion | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localised | |||
| Segmental | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Aphtha | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Extent | Localised | |||
| Segmental | ||||
| Diffuse | ||||
| Bleeding | Yes | |||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Ulcer | Number | Single (Solitary) | Site(s) | |
| Few | ||||
| Multiple | ||||
| Size | Largest diameter in mm | |||
| Bleeding | Yes: Spurting | |||
| Yes: Oozing | ||||
| No | ||||
| Stigmata of bleeding | Yes | |||
| No | ||||
| Scar | Number | Single | Site(s) | |
| Multiple | ||||
| Diverticulum | Number | Single | Site(s) | |
| Few | ||||
| Multiple | ||||
| Opening | Small | |||
| Large | ||||
| Fistula | Site(s) | |||
| Anal fissure | ||||
4.4 List of terms for ERCP.
The following terms shall be used to describe observations made during examination of the pancreas and biliary tract. They are divided by anatomic site according to the area visualized on ERCP.
4.4.1 List of terms for duodenum
The terms used for the duodenum in Table 8 shall be used to describe observations made in the duodenum
4.4.2 List of terms for papilla major.
The following terms shall be used to describe observations made during examination of the papilla major. It is useful to specify if the position of the papilla was normal, peridiverticular or intradiverticular.
Table 10. Terms for papilla major
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTES VALUES |
SITES |
| Normal | Normal | Site(s) | ||
| Abnormal Output or Content | ||||
| Blood | Site(s) | |||
| Pus | ||||
| Sludge | ||||
| Impacted stone | ||||
| Foreign body | ||||
| Parasites | ||||
| Stent | ||||
| Drain | ||||
| Abnormal Appearance | ||||
| Stenosis | Appearance | Benign | Site(s) | |
| Malignant | ||||
| Bulging | Site(s) | |||
| Congested | Site(s) | |||
| Lacerated | Site(s) | |||
| Tumor/Mass | Type | Frond-like/Villous | Site(s) | |
| Fungating | ||||
| Infiltrative | ||||
| Evidence of Previous Endoscopic Intervention | Type | Sphincterotomy: Biliary | Site(s) | |
| Sphincterotomy: Pancreatic | ||||
| Sphincterotomy: Biliary and Pancreatic | ||||
| Precut | ||||
4.4.3 List of terms for papilla minor.
The following terms shall be used to describe observations made during examination of the papilla minor.
Table 11. Terms for papilla minor
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTES VALUES |
SITES |
| Normal | Normal | Site(s) | ||
| Abnormal Output or Content | ||||
| Blood | Site(s) | |||
| Pus | Site(s) | |||
| Stent | Site(s) | |||
| Drain | ||||
| Abnormal Appearance | ||||
| Congested | Site(s) | |||
| Lacerated | Site(s) | |||
| Tumor/Mass | Type | Frond-like/Villous | Site(s) | |
| Fungating | ||||
| Infiltrative | ||||
| Evidence of Previous Endoscopic Intervention | Type | Sphincterotomy | Site(s) | |
| Precut | ||||
4.4.4 List of terms for pancreas.
The following terms shall be used to describe observations made during examination of the pancreas.
Table 12. Terms for pancreas
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTES VALUES |
SITES |
| Normal | Normal | Site(s) | ||
| Abnormalities | ||||
| Pancreas Divisum | Extent | Complete | ||
| Incomplete | ||||
| Irregularity | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Dilated | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Rarefaction (attenuation) of branches | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Stenosis | Length | in mm | Site(s) | |
| Obstruction | Appearance | Stone | Site(s) | |
| Tumor/Mass | ||||
| Completeness | Partial | |||
| Complete | ||||
| Stone | Number | Single | Site(s) | |
| Multiple | ||||
| Cavity | Number | Single | Site(s) | |
| Multiple | ||||
| Diameter | in mm | |||
| Chain of lakes | Site(s) | |||
| Extravasation | Site(s) | |||
| Fistula | Site(s) | |||
| Evidence of previous surgery | Site(s) | |||
| Stent | Site(s) | |||
4.4.5 List of terms for biliary system.
The following terms shall be used to describe observations made during examination of the biliary system.
Table 13. Terms for biliary system
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTES VALUES |
SITES |
| Normal | Normal | Site(s) | ||
| Abnormalities | ||||
| Cystic duct junction | Location from papilla | Lower than 2 cm | Site(s) | |
| Greater than 2 cm | ||||
| Irregularity | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Dilation | Extent | Prestenotic | Site(s) | |
| Localized | ||||
| Segmental | ||||
| Diffuse | ||||
| Rarefaction (attenuation) of branches | Extent | Localised | Site(s) | |
| Segmental | ||||
| Diffuse | ||||
| Stenosis | Length | in mm | Site(s) | |
| Number | Single | |||
| Multiple | ||||
| Extent | Localised | |||
| Segmental | ||||
| Diffuse | ||||
| Extrinsic Impression (non-stenotic) | Size | Long | Site(s) | |
| Short | ||||
| Obstruction | Appearance | Stone | Site(s) | |
| Tumor/Mass | ||||
| Completeness | Partial | |||
| Complete | ||||
| Stone | Number | specify if less than 5 | Site(s) | |
| Multiple | ||||
| Size | in mm | |||
| Filling defect(other than stone) | Appearance | Air bubbles | Site(s) | |
| Sludge | ||||
| Parasite | ||||
| T-tube | ||||
| Stent | Specify | Site(s) | ||
| Extravasation | Site(s) | |||
| Cavity | Number | Single | Site(s) | |
| Multiple | ||||
| Diameter | in mm | |||
| Fistula | Specify... | Site(s) | ||
| Evidence of previous surgery | Cholecystectomy Choledocho-duodenostomy Choledocho-enterostomy Cholecystoentero-stomy Liver transplantation |
Site(s) |
4.5 Additional Diagnostic and Therapeutic Procedures.
The following terms shall be used to describe additional diagnostic and therapeutic procedures made during endoscopy.
Table 14. Terms for additional diagnostic and therapeutic procedures
HEADINGS |
TERMS |
ATTRIBUTES |
ATTRIBUTES VALUES |
SITES |
| Diagnostic Procedures | ||||
| Biopsy | Device | Forceps | Site | |
| Snare | ||||
| Method | Cold | |||
| Hot | ||||
| Purpose | Histology | |||
| Microbiology | ||||
| Helicobacter pylori test | ||||
| Lesion | Specify | |||
| Cytology | Lesion | Specify | Site | |
| Chromoscopy | Type | Dye spreading | Site | |
| Staining | ||||
| Dye | Specify | |||
| Fluid aspiration | Site | |||
| Fluoroscopy | Type | Specify | Site | |
| Cholangioscopy | Type | Specify | Site | |
| Endosonography | Type | Specify using the dedicated terminology | Site | |
| Functional Measurement | Type | Specify | Site | |
| Therapeutic Procedures | ||||
| Foreign body removal | Type | Site | ||
| Polypectomy | Device | Forceps | Site | |
| Snare | ||||
| Method | Cold | |||
| Hot | ||||
| Result | Complete | |||
| Incomplete | ||||
| Retrieval of polyp | Retrieved | |||
| Not retrieved | ||||
| Sphincterotomy | Precut | Yes | ||
| Result | Successful | |||
| Unsuccessful | ||||
| Stone extraction | Result | Complete | ||
| Incomplete | ||||
| Not successful | ||||
| Lithotripsy | Type | Specify… | ||
| Result | Successful | |||
| Unsuccessful | ||||
| Cystostomy | Type | Transgastric | ||
| Transduodenal | ||||
| Guide-wire placement | Type | Specify | Site(s) | |
| Result | Successful | |||
| Unsuccessful | ||||
| Tube,/Drain Placement | Type | Nasobiliary | ||
| Nasocystic | ||||
| Nasoenteric | ||||
| Nasopancreatic | ||||
| Stent | ||||
| Result | Successful | |||
| Unsuccessful | ||||
| Percutaneous Gastrostomy (PEG) | Type | Specify | ||
| Type of removal | External | |||
| Internal | ||||
| Result | Successful | |||
| Unsuccessful | ||||
| Dilation | Type | Guided Bougie | Site | |
| Non-guided bougie | ||||
| Balloon | ||||
| Size | ||||
| Result | Successful | |||
| Unsuccessful | ||||
| Lesion | Specify | |||
| Injection | Injected material | Specify | Site | |
| Volume | Specify | |||
| Purpose | Hemostasis | |||
| Eradication of varices | ||||
| Tumor destruction | ||||
| Drug delivery | ||||
| Tattooing | ||||
| Result | Successful | |||
| Unsuccessful | ||||
| Ligation | Type | Specify | Site | |
| Number | Specify | |||
| Result | Successful | |||
| Unsuccessful | ||||
| Prosthesis | Type | Specify … | Site | |
| Length | in cm or mm | |||
| Diameter | in French or mm | |||
| Result | Successful | |||
| Unsuccessful | ||||
| Mucosal resection | Type | Specify… | Site | |
| Lesion | Specify… | |||
| Result | Successful | |||
| Unsuccessful | ||||
| Thermal Therapy | Type | Coagulation | Site | |
| Vaporisation | ||||
| Device | Monopolar electrical | |||
| Bipolar electrical | ||||
| Laser | ||||
| Argon beam | ||||
| Purpose | Hemostasis | |||
| Tissue destruction | ||||
| Tumor destruction | ||||
| Result | Successful | |||
| Unsuccessful | ||||
| Photodynamic therapy | Type | Specify | Site | |
| Purpose | Specify | |||
| Result | Successful | |||
| Unsuccessful | ||||
| Intraluminal radiation | Type | Specify | Site | |
| Purpose | Specify | |||
| Result | Successful | |||
| Unsuccessful | ||||
4.6 Complications
The following terms shall be used to describe complications.
Table 15. Terms for complications
| Complications |
| Cardio-respiratory |
| Perforation |
| Hemorrhage |
| Pancreatitis |
| Infection |
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