OMED - 6.0 Diagnosis

This list of terms for each examination indicates the diagnosis, single or multiple that the endoscopist feels is most likely on the basis of macroscopic findings. This is not necessarily the final diagnosis, which takes into account the findings of any additional procedures performed such as biopsy/cytology. The diagnostic list has been split into two parts: (i) Main diagnoses, ordered by expected prevalence; (ii) Other (rarer) diagnoses listed alphabetically. The decision on to which list a particular diagnosis appears is based upon the expected frequency of this finding in a European context. This "diagnosis" could be used to implement a "conclusion" field within any report generated. Such a conclusion would be based on a synthesis of all of the findings recorded. This is particularly true when a number of different lesions are described, such as in inflammatory bowel diseases at colonoscopy.

The Committee also recommends that it should be possible to record a "negative conclusion" as well as a positive one. It is often as important to record that a feature is not present as it is to describe that it is, for example, the failure to find any sign of bleeding when a patient presents with an apparent gastrointestinal bleed. It is suggested that it be possible to qualify a diagnosis by "certain", "suspected", "probably not present" and "definitely excluded".

Main Diagnoses	Attribute
Normal	Suspicion of
Reflux esophagitis	Established
Varices	Exclusion of
Benign stricture	Follow-up of
Malignant tumor
Barrett's esophagus
Ulcer
	Treatment of
Other Diagnoses
Achalasia
Benign tumor
Diverticulum
Fistula
Foreign body
Hiatus hernia
Mallory-Weiss tear
Monilial esophagitis
Non reflux esophagitis
Polyp
Post-operative appearance
Post-sclerotherapy appearance
Scar
Schatzki ring
Submucosal tumor

Main Diagnoses	Attribute
Normal	Suspicion of
Gastropathy:	Established
Erosive	Exclusion of
Erythematous (hyperemic)	Follow-up of
Hypertrophic
Hemorrhagic
Gastric mucosal atrophy
Suspicion of gastritis (in this case the choices "Established…"	Treatment of
Portal hypertensive gastropathy
Gastric ulcer
Bleeding gastric ulcer
Stomal ulcer
Malignant tumor: Specify if relevant: Gastric carcinoma
Polyps

Other Diagnoses
Angioectasia
Benign tumor
Bleeding of unknown origin
Dieulafoy lesion
Diverticulum
Early gastric cancer
Extrinsic compression
Fistula
Foreign body
Gastric retention
Helicobacter pylori
Papulous gastropathy
Parasites (should be added to the list in some countries)
Post-operative appearance
Scar
Submucosal tumor
Varices

Main Diagnoses	Attribute
Normal	Suspicion of
Duodenopathy:	Established
Erosive	Exclusion of
Erythematous (hyperemic)	Follow-up of
Congestive
Hemorrhagic
Duodenal ulcer
Bleeding duodenal ulcer	Treatment of
Ulcerogenic deformed duodenum

Other Diagnoses
Angioectasia
Benign tumor
Bleeding of unknown origin
Brunner's gland hyperplasia
Coeliac disease
Crohn's disease
Diverticulum
Fistula
Malignant tumor
Parasite
Polyp
Post-operative appearance
Scar
Submucosal tumor
Other (specify)

Main Diagnosis	Attribute
Normal	Suspicion of
Polyp(s)	Established
Malignant tumor :	Exclusion of
Primary	Follow-up of
Recurrent (post-operative/anastomotic)
Ulcerative colitis :
Quiescent
Active moderate	Treatment of
Active severe
Crohn's disease :
Quiescent
Active moderate
Active severe
Unspecified colitis
Diverticulosis
Diverticulitis
Radiation(al) colitis/proctitis
Hemorrhoids

Other Diagnoses
Angioectasia (vascular abnormality)
Bleeding of unknown origin
Condylomata
Foreign body
Fistula
Ileitis
Ischemic colitis
Lymphoma
Melanosis
Parasites (should be added to the list in some countries)
Polyposis coli
Pneumatosis coli
Post-operative appearance
Post-operative stricture
Proctitis
Pseudomembanous colitis
Solitary ulcer
Lipoma
Other (specify)

Main Diagnoses	Attribute
Failed pancreatogram	Suspicion of
Normal pancreatogram	Established
Chronic pancreatitis	Exclusion of
Pancreatic tumor	Follow-up of
Pancreatic cyst
Papillary stenosis
Tumor Ampulla of Vater
	Treatment of
Other Diagnoses
Abnormal biliary-pancreatic junction
Annular pancreas
Pancreas divisum
Pancreatic duct fistula
Pancreatic stone
Parasites
Other (specify)

Main Diagnoses	Attribute
Failed cholangiogram	Suspicion of
Normal cholangiogram	Established
Normal post-cholecystectomy cholangiogram	Exclusion of
Normal post-sphincterotomy cholangiogram	Follow-up of
Cholelithiasis
Choledocholithiasis
Cholecystolithiasis
Hepatic lithiasis	Treatment of
Cystic duct lithiasis
Cystic stump lithiasis
Mirizzi syndrome
Biliary tumor
Main Bile duct tumor
Klatzkin tumor
Gallbladder tumor
Papillary stenosis
Ampullary tumor
Stent occlusion

Other Diagnoses
Abnormal biliary-pancreatic junction
Bile duct fistula
Bile duct occlusion
Bile leak
Biliary stricture
Caroli's disease
Choledochal cyst
Choledochocele
Cirrhosis
Hemobilia
Papillary stenosis
Parasites
Sclerosing cholangitis
Sump syndrome
Suppurative cholangitis
Tumor of the gallbladder
Other (specify)