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1 , slide film video tape, color printer. database,.. database.. Maratka 1984 OMED (Orgarnization Mondiale d' Endoscopie Digestive, World Society of Digestive Endoscopy) terminology OMED.. (European Society for Gastrointestinal Endoscopy; ESGE),,,,,, OMED Maratka,, (Fujinon, Olympus, Pentax) OMED terminology 1996 minimal standard terminology for a computerized endoscopic database (MST). 1991, 1994 OMED database 3

2 4 21. database database,,.,,,.. database database. (structure of an endoscopic record).,,,,,,,,,,,,,,, (Table 1).. 1) (Reasons for examination).,,, 4. (1) : (, ),,,,,.. Table 1. Structure of an Endoscopic Record 1. Patient demographic data 2. Date of procedure 3. Endoscopist 4. Type of endoscopic examination proposed 5. Instruments used 6. Reasons for examination 7. Medication details (Anesthesia, Anethesiologist, Analgesia, Sedation...) 8. Anatomical extent of examination 9. Limitation (s) of examination 10. Findings and specimens obtained 11. Endoscopic diagnosis 12. Therapeutic interventions and results 13. tation of images captured 14. Complications 15. Comments 16. Results of biopsies and other late tests 17. Final diagnosis

3 5 (2) :,,,, (,,, ), (volvulus),,,,.,,. (3) :, (occult blood loss),,. (4) :. 2) (1) :,. (term).,. database, free-text field. OMED terminology.. OMED terminology.. minimal standards of terminology and documentation. (stenosis); (segment) (narrowed) (stricture) (stenosed) (compressed) stenosis. Red mucosa, erythema, congested mucosa, hyperemia; 4. Erythematous mucosa (diffuse) congested mucosa erythema (edema), (swollen) (friable mucosa). hyperemia erythema edematous congested mucosa. (erosion), (aphtha); OMED terminology (erosion)...

4 6 21. (red halo) (spot). congested erythematous mucosa. (tumor), (mass); (neoplastic nature). (granular), (papule),,. (angioectasia); (telangiectasia) (angiodysplasia). (scar); (fibrosis).. (occlusion, obstruction); OMED terminology obstruction (intraluminal) (foreign body) occlusion (intrinsic) obstruction 1) (tubular) (exophytic), 2) ERCP, occlusion. (2) :,,,, OMED terminology,,,, (Table 2). database ( ) (attribute) (attibute value),,. Database database Table 2. General Organization of the Terminology 1. rmal Should be used if the organ has been entirely examined and everything is normal in it. 2. Lumen Contains all terms regarding an abnormality of the size of the organ, any deformity, compression, and the evidence of previous surgery. 3. Contents Terms describing the presence of various materials within the organ. 4. Mucosa Terms describing patterns of the mucosa that are mainly diffuse and may involve all the mucosa of one limited area. These terms are not applicable to individual lesions. 5. Flat lesions Terms to be used for individual lesions that remain in the plane of the mucosa. 6. Protruding lesions Terms to be applied to lesions growing above the plane of the mucosa. 7. Excavated lesions Terms to be applied to lesions whose surface is beneath the plane of the mucosa

5 7. (lumen):,,, (haustration). (, ),,,,. (content):,, (exudate),.,, hematin. (mucosa):, (erythematous), (congested),, (friable),,,,. (flat lesion):.,,. (protruding lesion):,,,,,. (5,, ),,,,,,,,. (excavated lesion):,,,,,,.,,,.. 3),,,,,,,, stent,,,. 4).,, S,,,,,,,,,,.,,,,,. X- X-. S (anal verge) cm cm. loop cm loop 180 cm. loop

6 8 21. Rectosigmoid: cm Proximal sigmoid: cm Mid-descending: cm Splenic flexure: cm Midtransverse: cm Hepatic flexure: cm Cecum: cm 5),,,,,,,,,,,,,,,,,,,,,,,,,...,,,.... database. 1) :., ) :., ) :. 7 1, ) :. 7 79, ) : , ) :. 20 3, ) Maratka Z: Terminology, definitions and diagnostic criteria in digestive endoscopy. Scand J Gastroenterol 19(supple 103): 1, ) Gouveia-Oliveira A, Ruposo VD, Azevedo AP, Salgado NC, Almeida I, Silva AM, Galvao de Melo F, Pinto Correira J: SISCOPE: A multiuser information system for gastrointestinal endoscopy. Endoscopy 23: 272, ) Maratka Z: The OMED Data Base: Standard for nomenclature, Endoscopy 24(Supple 2): 455, ) ASGE Computers Committe. Standard format and content of endoscopic procedure report. American Society for Gastrointestinal Endoscopy, ) Gouveia-Oliveira A, Raposo VD, Salgado NC, Azevedo AP, Almeida I, Galvao de Melo F, Pinto Correira J: Modification of the OMED nomenclature: A system approach based on the SISCOPE data model. Endoscopy 24(supple 2): 457, ) Maratka Z: Terminology, definitions and diagnostic criteria, digestive endoscopy, 4th ed, Hamburg, Germany, rmed Verlag, ) Crespi M, Delvaux M, Schapiro M, Venables C, Zwiebel F, ad hoc Task Forces of the Committee:

7 9 Minimal standards for a computerized endoscopic database. Am J Gastroenterol 89: S144, ) Crespi M, Delvaux M, Schapiro M, Venables C, Zwiebel F: Working party report by the committee for minimal standards of terminology and documentation in digestive endoscopy of the european society of gastrointestinal endoscopy database. Am J Gastroenterol 91: 191, ) Cooper GS: Outcomes research in endoscopy; current status and future direction. Gastrointest Endosc 46: 374, 1997

8 10 21 ( database ). COLONOSCOPY 1. LIST OF REASONS FOR PERFORMING LOWER GI ENDOSCOPIES 1.1. Symptoms Hematochezia Melena of unknown origin Diarrhea Abdominal distress/pain Modification of bowel habits Anemia Weight loss 1.2. Diseases Polyps Colorectal cancer Colonic obstruction Diverticula Attribute: Inflammatory bowel diseases Suspected... Crohn' s disease Established... Ulcerative colitis Exclusion of... Intestinal tuberculosis Follow-up of... Behcet' s disease For therapy of... Volvulus Angioectasia Ischemic colitis Pseudomembranous colitis (specify) 1.3. Assessment Preoperative Postoperative Occult blood loss Screening (specify) 1.4. Diagnostic sampling : specify 2. MAJOR SITES FOR LOCATION OF FINDINGS IN THE COLON Anus Rectum Sigmoid colon Descending colon Splenic flexure Transverse colon

9 11 2. Continued Hepatic flexure Ascending colon Cecum Ileocecal valve Ileum Whole colon Surgical stoma 3. LIST OF TERMS Terms Attributes Attribute values Sites rmal Lumen Dilated Stenosis Appearance Extrinsic Benign intrinsic Malignant intrinsic Length (cm) Traversed? Yes/ Evidence of previous surgery Type Colocolonic Anastomosis Ileocolonic Anastomosis Colostomy Haustrations Appearance rmal Decreased Extension Localized Contents Blood Kind of blood Red Clot Hematin (altered blood) Foreign body Exudate Stool Mucosa Vascular pattern Appearance rmal Decreased Extension Localized Erythematous (hyperemic) Extension Localized

10 Continued Terms Attributes Attribute values Sites Congested (edematous) Extension Localized Granular Extension Localized Friable Extension Localized Bleeding Yes Contact bleeding Spontaneous bleeding Petechiae Number Few Pseudomembrane Extension Localized Melanosis Extension Localized Flat lesions Angioectasia Number Single Few Size Small Medium Large Bleeding Yes stigmata bleeding Protruding lesions Polyp(s) Number If less than 5, specify If more than 5: Many Extension Localized Size In mm Pedicle Sessile Pedunculated

11 13 3. Continued Terms Attributes Attribute values Sites Bleeding Yes Stigmata bleeding Pseudopolyps Extension Localized Tumors Size Small Medium Large (diameter in mm) Length In cm Type Submucosal Fungating Ulcerated Infiltrative Frond-like/Villous Obstructing Partial Complete Circumferential Yes Bleeding Yes Stigmata of bleeding Hemorrhoids Bleeding Yes Suture granuloma Number Single Few Condylomas Excavated lesions Erosion Number Single Few Extension Localized Bleeding Yes Stigmata of bleeding Aphtha Number Single Few Extension Localized

12 Continued Terms Attributes Attribute values Sites Bleeding Yes Stigmata of bleeding Ulcer Number Single (Solitary) Few Size Largest diameter in mm Bleeding Yes Stigmata of bleeding Scar Number Single Diverticulum Number Single Few Fistula Anal fissure 4. ENDOSCOPIC DIAGNOSIS 4.1. Main diagnoses rmal Attribute: Polyp(s) Suspected... Malignant tumor Established... Primary Exclusion of... Recurrent (postoperative/anastomotic) Follow-up of... Ulcerative colitis Treatment of... Quiescent Active moderate Active severe Crohn' s disease Quiescent Active moderate Active severe Intestinal tuberculosis Active state Healing state Healed stage Behecet' s disease Unspecified colitis Diverticulosis Diverticulitis Radiation(al) colitis/proctitis Hemorrhoids

13 15 4. Continued 4.2. diagnoses Angioectasia (vascular abnormality) Bleeding of unknown origin Condylomata Foreign body Fistula Ileitis Ischemic colitis Lymphoma Melanosis Polyposis coli Pneumatosis coli Postoperative appearance Postoperative stricture Proctitis Pseudomembranous colitis Solitary ulcer (specify) 5. ADDITIONAL DIAGNOSTIC AND THERAPEUTIC PROCEDURES 5.1. List of Terms Terms Attributes Attribute values Sites Biopsy Device Forceps Site Snare Method Cold Hot Purpose Histology Microbiology Lesion Specify Cytology Lesion Specify Site Staining Site Fluid aspiration Site Foreign body removal Type Site Polypectomy Device Forceps Site Snare Method Cold Hot Result Complete Incomplete Retrieval of polyp Retrieved t retrieved Dilation Type Bougie Site Balloon

14 Continued Terms Attributes Attribute values Sites Size Result Successful Unsuccessful Hemostasis Lesion Specify Site Type Injection therapy Thermal therapy 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 Tumor destruction Type Specify... Site Result Successful Unsuccessful Lesion Specify... Site Complications Cardiorespiratory Perforation Hemorrhage Infection

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untitled The Korean Journal of Gastrointestinal Endoscopy Room C 캡슐내시경진단리포트하기 금보라 고려대학교의과대학내과학교실 How to Report the Capsule Endoscopy Results Bora Keum, M.D. Department of Internal Medicine, Korea University College