Normal and Inflammatory:

-- No diagnostic abnormality.   

-- Moderate non-specific chronic duodenitis, favor reactive.   

-- Focal moderate peptic duodenitis with gastric metaplasia and acute inflammation.    

-- Active gluten-sensitive enteropathy (Celiac sprue), Marsh-Oberhuber classification 3b.   

Infectious:   

-- Intestinal Giadiasis with multiple luminal clusters of trophozites. 

-- Severe cytomegalovirus esophagitis with mucosal erosion and granulation tissue.  

-- Duodenal infection by mycobacterium avium intracellulare in sheet, confirmed by Ziehl - Neelsen stain. 

Neoplastic:   

-- Dx Heading above font = 04Heading; Style = 04DxHeadings.

-- Dx text (i.e. this section):  font = 05BodyT (i.e. Normal); Style = 05 DxBodyS.

=============

Clinical scenario:  .       

Stomach, antrum, biopsy:     

-- No diagnostic abnormality.

-- No Helicobacter organism identified on special stain.

Slides examined:   H&E   x  1

CPT code:        88305 x  1

=============

Clinical scenario:  .       

Stomach, antrum, biopsy:     

-- Reactive gastropathy with focal superficial vascular congestion, non-specific changes.

-- Minimal chronic inflammation. 

-- No active gastritis, granuloma or glandular dysplasia.

-- No helicobacter organism is identified on special stain.

Slides examined:   H&E   x  1

CPT code:        88305 x  1, 88311 x 1

=============

Clinical scenario:  45-year old woman.       

Stomach, Sleeve gastrectomy:       

-- No diagnostic abnormality.

Slides examined:   H&E   x  1

CPT code:        88307 x  1

=============

Clinical scenario:  59-yo woman with epigastric pain. Mucosal erythema on endoscopy.   

Stomach, antrum, biopsy:     

-- Diffuse moderate chronic inactive gastritis, etiology uncertain.

-- No mucosal erosion, granuloma, glandular dysplasia or carcinoma.

-- No Helicobacter organism identified.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This is probably most frequently encountered histologic "diagnosis" in gastric biopsy. The findings are non-specific and can be seen in a wide variety of clinical settings. In such a scenario, reporting relevant negative findings based on patient's age, sex and clinical presentation is more important and helpful than a wild speculation of possible etiologies.

=============

Clinical scenario:  16-yo girl with chronic diarrhea.   

Stomach, antrum and corpus, biopsy:           

-- Multifocal patchy moderate chronic active gastritis and a poorly-formed epithelioid granuloma, suggestive of Crohn's disease (see Note).

-- No mucosal erosion, diffuse superficial lymphoplasmacytosis or stromal eosinophilia.

-- No Helicobacter organism identified on a special stain.

Note: Given the clinical history and histologic findings in the biopsy samples of the colon, Crohn's disease involving stomach is strongly favored.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

Diagnosis of Crohn's disease based solely on findings in gastric biopsy can be difficult. This example is part of  a series of GI biopsy including those from colon and terminal ileum that are also abnormal. If only gastric biopsy is available, it's helpful to raise such diagnostic possibility.

=============

Clinical scenario:  24-yo man with abdominal discomfort. R/o H. Pylori.            

Stomach, antrum, biopsy:     

--  Diffuse moderate to severe chronic active gastritis secondary to H. pylori infection.

--  Innumerable Helicobacter organisms consistent with H. pylori are revealed by Diff-Quik stain.

--  No mucosal erosion, lymphoepithelial lesion, glandular dysplasia or malignancy.

Slides examined:   H&E   x  X

CPT code:        88305 x 1

Editor's comment:

Although the diagnosis is straightforward, reporting absence or presence of relevant findings (i.e. erosion, lymphoma) is appropriate instead of listing  "No dysplasia or carcinoma" in this age group.    

=============

Clinical scenario: 48-yo man with chronic epigastric discomfort.

Stomach, antrum, biopsy:    # 

-- Diffuse, superficial, moderate chronic gastritis with focal activity and dense lymphoid aggregate formation, suggestive but not diagnostic of H.Pylori infection (see Note).

-- No lymphoepithelial lesion, mucosal erosion, granuloma, glandular dysplasia or malignancy.

-- No Helicobacter organism identified with special stains.

Note: The histological findings are very suggestive of gastritis associated with H. pylori infection.  However, special stains including immunohistochemical stains are negative.  Further clinical work-up (e.g. urea breath test) may be considered.

Only antral/oxynic biopsies are received.  Ideally the diagnosis of helicobacter requires 2 biopsies from the antral and 2 from oxyntic mucosa

Histologic changes are highly suggestive of helicobacter infection, although the organisms are note identified.  In the absence of atrophy, metaplasia, lymphocytic gastritis and diffuse reactive changes, the most likely causes of this association are sampling effect (only antral/oxyntic mucosa is smapled), treatment with ppis, recent antibiotics or eradication therapy, all of which can reduce the number of helicobacter to undetectable level levels or that the patient has had h. Pylori recently eradicated

Editor's comment:

Because of radiation activity, caution should be taken when offering urea breath test to pediatric patients.

=============

Clinical scenario:  52-year old man with reflux disease.       

Stomach, fundus and corpus, biopsy:     

-- Reactive gastropathy with changes consistent with effect of proton pump inhibitor.

-- No active inflammation, mucosal erosion, glandular dysplasia or neuroendocrine hyperplasia.

-- No Helicobacter organism identified.

Slides examined:   H&E   x  2

CPT code:        88305 x  1, 88312 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Stomach, antrum, biopsy:     

-- Diffuse prominent reactive gastropathy, etiology uncertain (see Note).

-- No polarizable exogenous material, vascular thrombosis, glandular dysplasia or malignancy.

-- No Helicobacter organism identified on Diff-Quick stain.

Note: The etiology underlying the observed mucosal erosion and reactive gastropathy is not histologically apparent. The findings raise the possibility of a medication-induced injury. These findings, however, are not pathognomonic and can be seen in other types of erosive gastropathy. Clinical correlation is recommended.

Slides examined:   H&E   x  2

CPT code:        88305 x  1, 88312 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  70-year old man with h/o hepatocellular carcinoma; diffuse mucosal inflammation on endoscopy..

Stomach, antrum, biopsy:     

-- Consistent with  internal radiation therapy–related gastric mucosal injury.

-- No ischemic gastritis, glandular dysplasia or carcinoma.

Note: Sections reveal corpral and antral mucosa with inflammatory infiltrates, mild to moderate cytologic atypia, stromal edema, and round blue and dark microspheres in the stromal blood vessels. The findings are consistent with the above diagnosis (ref.)

Reference: D-L Luo & K.C. Chan: Basophilic Round Bodies in Gastric Biopsies Little Known by Pathologists: Iatrogenic Yttrium 90 Microspheres Deriving From Selective Internal Radiation Therapy.  INT J SURG PATHOL October 2013 21: 535-537.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

=============

Clinical scenario: 72-year old woman with iron-deficient anemia. R/O upper GI bleeding or malignancy      

Stomach, corpus, biopsy:       

-- Moderate mucosal siderosis and focal mucosal erosion and acute inflammation (see Note).

-- No active hemorrhage, vascular ectasia, glandular dysplasia or carcinoma.

Note: The presence of insoluble iron deposits is confirmed by iron stain.  The iron deposition is predominantly in stromal cells and occasionally as extracellular coarse crystals. Although hemochromatosis remains a possibility, the etiology underlying the mucosal siderosis in this case is most likely of exogenous iron supplement intake.  History of iron supplement intake is required to confirm the diagnosis.

Slides examined:   H&E   x  1

CPT code:        88305 x  1, 88311 x 1

Editor's comment:

The most common cause of mucosal siderosis (i.e., insoluable iron deposition) in elderly is excessive iron-supplement intake, which often in turn results in mucosal erosion and blood loss. This can cause or aggravate iron-deficient anemia. The vicious cycle continues when the patient increases intake of the iron-supplement in an attempt to correct the worsening anemia. Thus, bringing this to clinician's attention helps eliminate this potential cause.

=============

Clinical scenario: 63-year old man. Portal hypertension 2nd to liver cirrhosis. r/o GI bleeding      

Stomach, corpus and antrum, biopsy:       

-- Gastric mucosal siderosis, epithelial type / stromal type, confirmed by iron stain (see Note)

-- No diagnostic features of portal hypertensive gastropathy.

-- No significant inflammatory infiltrates, hemorrhage, glandular dysplasia or carcinoma.

Note: The presence of insoluble iron deposits is confirmed by iron stain.  The underlying etiology is not histologically apparent.  Main differential diagnosis may include prior mucosal hemorrhage, "iron-pill gastritis", and systemic hemochromatosis. Clinical correlation is recommended.

Reference:  Marginean EC, Bennick M, Cyczk J, Robert ME, Jain D.: Gastric siderosis: patterns and significance. Am J Surg Pathol. 2006 Apr;30(4):514-20.

Slides examined:   H&E   x  1

CPT code:        88305 x  1, 88311 x 1

Editor's comment:

The histologic patterns of mucosal siderosis (i.e., intraepithelial, stromal etc.) varies with underlying etiologies. However, such correlations are not very reliable. In addition, some of these causes are rarely encountered on gastric biopsy but may be easily detected via other lab tests. Thus, providing a short list of differential diagnosis can help further work-up. 

=============

Clinical scenario:  81-year old woman with stomach pain and decrease in appetite.        

Stomach, antrum and pylorus, biopsy:       

-- Prominent reactive gastropathy and focal intestinal metaplasia, suggestive but not diagnostic of bile reflux gastropathy (see note)

-- No mucosal erosion, active inflammation, granuloma, glandular dysplasia or carcinoma.

-- No Helicobacter organism identified on special stain.

Note:  The biopsy specimen shows diffuse reactive gastropathy with stromal edema, surface epithelial atrophy and degeneration.  Although presence of bile is generally considered to be a required feature for a definitive diagnosis of bile reflux gastropathy, the histological changes in this biopsy would be most compatible with bile reflux gastropathy if consistent with endoscopic findings.

Slides examined:   H&E   x  2

CPT code:        88305 x  1, 88312 x 1

=============

Clinical scenario: 47-year old woman.       

Stomach, Sleeve gastrectomy:       

-- Diffuse moderate chronic active gastritis with mucosal atrophy (atrophic gastritis), etiology uncertain. 

-- No active / acute inflammation, neuroendocrine neoplasia or glandular dysplasia.

-- No Helicobacter organism identified on special stain.

Note: Etiology underlying the observed atrophic gastritis is not histologically apparent. Main etiologic consideration should include parietal hernia, chronic chemical injury, H. pylori infection and, much less likely in this age group, autoimmune gastritis.

Slides examined:   H&E   x  2

CPT code:        88305 x  1, 88312 x 1.

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Stomach, random mucosal biopsy:      

-- Lymphocytic gastritis with intraepithelial lymphocytes (> 30 per 100 lining foveolar cells), mucosal atrophy and focal thickened basal lamina (see Note).

-- Focal possible mucosal erosion and mild acute associated inflammation.

-- No granuloma or glandular dysplasia. 

Note: 02958203.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  59-yo woman with mass lesion; hx/ right breast cancer, s/p lumpectomy 2 years ago; s/p chemoradiation therapy.   

Stomach, antrum, biopsy:     

-- Gastric xanthoma and prominent diffuse reactive gastropathy (see Note).

-- No active inflammation, granuloma, glandular dysplasia or malignancy.

Note:  The gastric xanthoma involves a portion of the biopsy and is present as small clusters of foamy histiocytes in the lamina propria. Special stains, with adequate controls, show that the xanthomatous cells are negative for cytokeratin and mucicarmine but are positive for CD68, a profile confirming the diagnosis. In general, gastric xanthoma is of little clinical significance and is not correlated with hypercholesterolemia.

Slides examined:   H&E   x  1

CPT code:        88305 x  1, 88342 x 2, 88311 x 1

Editor's comment:

The most important differential diagnosis is signet-ring cell adenocarcinoma, especially in elderly or patients with prior history of adenocarcinoma. Additional studies such as PAS-D and Acid-Fast stains may be used if Whipple's disease needs to be excluded. The note may help avoid a phone call from the clinician.unfamiliar with the management of this diagnostic entity.

=============

Clinical scenario:  .       

Stomach, fundus and corpus, biopsy:      

-- Cystic fundic gland polyp.

-- No mucosal erosion, active inflammation or glandular dysplasia.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Stomach, corpus and antrum, biopsy:      

-- Hyperplastic polyp with focal erosion and granulation tissue formation.

-- No glandular dysplasia or carcinoma.

-- No Helicobacter pylori organisms identified.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario: 57-year old woman with a 3-cm antral polyp .       

Stomach, antrum, polypectomy:     

-- Gastric inflammatory fibroid polyp, confimed by positive immunohistochemical stain for CD34.

-- No mucosal erosion, glandular epithelial dysplasia or carcinoma.

Slides examined:   H&E   x  4

CPT code:        88307 x  1, 88342 x 4

Editor's comment:

Although a well-sampled case is generally straightforward, differential diagnosis may also include solitary fibrous tumor, perineuroma, inflammatory myofibroblastic tumor and GIST.    

=============

Clinical scenario: 51-year old man. Prominent vascular pattern on endoscopy .       

Stomach, antrum, biopsy:     

-- Prominent gastric vascular ectasia (GAVE) and stromal hemosiderin-laden macrophages.

-- No active inflammation, mucosal erosion, active hemorrhage or glandular dysplasia.

-- No Helicobacter pylori organisms identified.

Slides examined:   H&E   x  X

CPT code:        88305 x 1

Editor's comment:

A main sequela of gastric vascular lesion is hemorrhage when eroded. Thus, report should indicate whether such secondary changes are present (line-2).   

=============

Clinical scenario: 56-year old man. h/o cirrhosis 2nd to Eth. Diffuse mucosal atrophy.       

Stomach, corpus and antrum, biopsy:     

-- Vascular ectasia, stromal fibrosis and glandular atrophy consistent with portal hypertensive vasculopathy .

-- No active inflammation, mucosal erosion, active hemorrhage or glandular dysplasia.

-- No Helicobacter pylori organisms identified. 

Slides examined:   H&E   x  X

CPT code:        88305 x 1

Editor's comment:

Although histologic changes can occasionally be quite revealing, diagnosis of gastric portal hypertensive vasculopathy frequently requires correlation with history of long-standing portal hypertension. It's appropriate to indicate the changes are "suggestive of" or "consistent with" the diagnosis.    

=============

Clinical scenario:  .       

Stomach, antrum, biopsy:     

-- Focal low-grade glandular epithelial dysplasia in two of five microscopic fragments.

-- Extensive intestinal metaplasia with goblet cells.

-- Mucosal atrophy and diffuse mild chronic gastritis.

-- No high-grade dysplasia or invasive carcinoma.

Note: 02958203.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Stomach, antrum, biopsy:     

-- High-grade epithelial dysplasia in four of five microscopic fragments.

-- Cannot exclude superficially invasive carcinoma.

-- No mucosal erosion or necrosis.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Stomach, antrum and corpus, biopsy:     

-- Invasive gastric adenocarcinoma with signet-ring cell features, two small microscopic fragments.

-- Cannot evaluate the depth of invasion and tumor extent due to limited tissue sample.

-- Diagnosis confirmed by Mucicarmin stain and immunohistochemical stains.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Distal stomach, partial gastroduodenectomy:     

-- Invasive gastric adenocarcinoma, poorly differentiated with signet-ring cell feature (see Tumor Synopsis and Note).

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

To prepare "Synoptic Report" with an on-line tool, go to  Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.

=============

Clinical scenario:  .       

Organ, site, surgical procedure:     

-- Dx Heading above font = 04Heading; Style = 04DxHeadings.

--

Note: 02958203.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Stomach, corpus, biopsy:     

-- Gastrointestinal stromal tumor (GIST) in one of three microscopic fragment, diagnosis confirmed by immunohistochemical stains for C-kit and DOG-1.

-- No tumor necrosis, significant cytological atypia or mitotic figure.

-- No mucosal involvement is identified in this biopsy

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Stomach, corpus, partial gastrectomy:     

-- Gastrointestinal stromal tumor (GIST), epithelioid type (see Tumor Synopsis).

-- No tumor is present at the examined resection margins.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

To prepare "Synoptic Report" with an on-line tool, go to  Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.

=============

Clinical scenario: 57-year old woman with a 3-cm antral polyp .       

Stomach, antrum, polypectomy:     

-- Gastric inflammatory fibroid polyp, confimed by positive immunohistochemical stain for CD34.

-- No mucosal erosion, glandular epithelial dysplasia or carcinoma.

Slides examined:   H&E   x  4

CPT code:        88307 x  1, 88342 x 4

Editor's comment:

Although a well-sampled case is generally straightforward, differential diagnosis may also include solitary fibrous tumor, perineuroma, inflammatory myofibroblastic tumor and GIST.    

=============

Clinical scenario:  .       

Distal stomach, partial gastrectomy:     

-- Prominent gastric ulcer, at least 1.0 cm in diameter, transmural (perforating) with associated serosal acute inflammation and focal fibrosis, etiology uncertain.

-- No definite ischemic change, vascular thrombosis, polarizable exogenous material or helicobacter organism.

-- Focal small mucosal erosion of adjacent duodenum.

-- Proximal and distal resection margins are free of mucosal erosion, glandular dysplasia or malignancy.

Note: 02958203.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario: 51-year old man, h/o reflux disease; small antral nodule on upper GI endoscopy.          

Stomach, antrum, biopsy:     

-- Fundus-like mucosa with superficial reactive gastropathy, consistent with fundic metaplasia with parietal cell hyperplasia of the antrum (see Note).

-- No active inflammation, mucosal erosion, glandular dysplasia or carcinoma

Note: The specimen is labeled as "antral nodule" but exhibits fundus-type glands.  This most likely represents fundic metaplasia with parietal cell hyperplasia of the antrum, a lesion possibly associated with long term use of omeprazole.  Correlation with drug history is recommended.

Reference: Declich P. et al.: Fundic metaplasia with parietal cell hyperplasia of the antrum: a lesion possibly associated with long term use of omeprazole.  Am J Gastroenterol. 1999 Aug;94(8):2317-9.

Slides examined:   H&E   x  1

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.         

=============

Clinical scenario:  .       

Organ, site, surgical procedure:     

-- Dx Heading above font = 04Heading; Style = 04DxHeadings.

--

Note: 02958203.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.