Operative Report

Preoperative Diagnosis:
Bleeding gastric ulcer

Postoperative Diagnosis:
Bleeding gastric ulcer

Procedure Performed:

1. Open Hemigastrectomy
2. Open Billroth II Anastomosis (Gastro-jejunal bypass)

Description:
An open hemigastrectomy was conducted to remove the portion of the stomach affected by the bleeding gastric ulcer. Following resection of the portion of ulcerated stomach, a Billroth II anastomosis was performed to create a direct connection between the remaining stomach and the jejunum, restoring gastrointestinal continuity.

Discharge Summary

Hospital Course

The patient was transferred from facility A, where he experienced 12 hours of hematemesis requiring transfusions with 14 units of red blood cells and 6 units of fresh-frozen plasma. 

Upon admission to facility B, a gastroscopic diagnostic examination revealed a 4- by 2-centimeter gastric ulcer with visible vessels and bleeding. 

He was then taken to the operating room, where a open hemigastrectomy was performed. In addition, an open Billroth II anastomosis (bypass) from the stomach to the jejunum was performed.

He continued on iron supplements for continued treatment of acute blood loss anemia.

Answers

Diagnoses:

1. K25.4 Chronic or unspecified gastric ulcer with hemorrhage
2. D62 Acute blood loss anemia
   

Rationale

The documentation does not state whether the ulcer is acute or chronic, so the default code would be K25.4 for unspecified.

Patient is still be treated for acute blood loss anemia at facility B.

Procedures:

0DB60ZZ Excision, Stomach (0DB6)

0D160ZA Bypass, Billroth II Bypass, Stomach (0D16)

0DJ68ZZ Inspection of stomach, Via Natural or Artificial Opening Endoscopic

Rationale: Open approach for this procedure. Subtotal gastrectomy (partial gastrectomy) is performed to remove the ulcer.

The stomach is reconstructed by a Billroth II bypass of the jejunum to be sutured to the wall of the stomach.

Prior to the open surgery, patient had a diagnostic gastroscopy examination