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Reporting of Gastric Biopsies

(Non-Neoplastic Lesions)

Dr Sampurna Roy MD

 

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Indication of gastric biopsies for non-neoplastic conditions:

1.  Endoscopic evidence of chronic gastritis or peptic ulcer.
(Remember -  Normal endoscopic finding does not necessarily rule out histological gastritis).

2.  Patients with non-ulcer dyspepsia to assess the Helicobacter pylori status.

3.  Grading of gastritis.

4.  Report other forms of gastritis.

5.  Further biopsy is indicated to assess healing and to differentiate between regenerative changes and true dysplasia.


Acute gastritis is rarely biopsied.

 

Biopsy sites to assess H. pylori associated gastritis:

- Two biopsies from middle antrum (on lesser and greater curvature, 2-3 cm  from  pylorus).

- Two biopsies from body (lesser curvature and middle of greater curvature).

- One biopsy from the incisura angulus.
 

A systematic approach is necessary for reporting gastric biopsies suspected of having inflammatory lesions.

Good communication between endoscopist and pathologist is necessary.

Gastroenterologist and pathologist should jointly design a tissue submission form.

A diagram of the stomach is useful. The endoscopist can indicate the lesion on the diagram.

The request form should include the following information:

- Age and sex

- Symptoms

- Clinical impression

- Endoscopic findings

- Site is crucial. Example- Gastritis of antrum and pangastritis have different clinical connotations and risk potential. ( Antral gastritis associated with duodenal ulcer. Pangastritis with  gastric ulcer/cancer ). Metaplasia in body type mucosa and loss of specialised cells (due to inflammation) can cause it to look as antral mucosa.

- History of  intake of drugs  (Example: NSAIDS) 

- History of pernicious anaemia

- History of immunosuppression - The history prompts the pathologist to carefully examine the biopsy for infection  (eg. cytomegalovirus).

- Relevant surgical operation.

- Family history of gastric carcinoma or familial adenomatous polyposis

- Results of previous gastric biopsies
 

Assessment of the biopsy :

- Type of mucosa included in the biopsy. In gastritis, antral and corpus biopsies are to be assessed separately.

Biopsy  >   Normal  or  Abnormal

- Abnormal biopsy >   Focal  or   Diffuse lesion (ie. involve surface epithelium, glandular component or stroma., or all three)

- Inflammation > 

i) Type (acute, chronic, mixed,  lymphocytic, plasmacytic, eosinophilic).

ii) Site (surface epithelium, pits, stroma, glands).

- Ulceration > Present or absent

- Presence of gastritis > 

- Ratio of stroma to glands >   Normal or abnormal 

Ratio altered due to i) too much stroma  ii) loss of normal mucosal component  iii) due to increased cellularity.

- Expansion of mucosa >

i) pit expansion, ii) glandular expansion, iii) expansion by inflammatory infiltrate,  iv) abnormal cellular infiltrate

- Distortion of glands >

Note whether the glands are lined up parallel to each other . Branching and irregularity  noted in chemical gastritis & Menetrier's disease.

- Metaplasia >  Intestinal, pyloric, pancreatic , ciliated

- Blood vessels > Normal or abnormal
   Abnormal features:  Vascular ectasia in chemical gastritis, thrombosed, thickened, atypical features, tumour emboli.

- Microorganisms > Fungi, viral inclusions

- Regenerative changes > Further levels done to  rule out dysplasia.

Special Stains: 

PAS-  Highlight Candida albicans or other fungi.

AB/PAS-  Intestinal metaplasia is demonstratrated.

High iron diamine/alcian blue- To classify the type of intestinal metaplasia on the basis of mucin type.

Cresyl fast violet, Gimenez, Giemsa,  half Gram, toluidene blue, Warthin starry - To demonstrate Helicobacter pylori

Immunohistochemistry:

To demonstrate specific inclusions (CMV , herpes virus)

Anti H. pylori antibody -  Not used routinely. ( Used when organisms are few in number) 
 

Grading:

1. Chronic inflammation:  Increase in lymphocytes and plasma cells in the lamina propria .
Grading: Mild, moderate & severe increase in density.

2.  Activity:  Neutrophil polymorph infiltration of the lamina propria, pits or surface epithelium.
Grading: Mild: Less than 1/3rd of pits & surface infiltrated .
Moderate: 1/3rd   to  2/3rd            "         "
Severe:   More than  2/3 rd           "         "   

3.  Atrophy:   Loss of specialised glands from corpus or antrum. Grading: Mild, moderate or severe loss.

4.  Intestinal metaplasia: 

Grading: Mild: Less than 1/3rd of mucosa involved

Moderate: 1/3rd - 2/3rd                 "       "

Severe:  More than 2/3rd               "       "

5. Helicobacter pylori: 

Grading:   Mild colonisation: Scattered organisms covering less than 1/3rd of the surface.

Moderate: 1/3rd - 2//3rd  of the surface

Severe: Large clusters or continuous layer over more than 2/3rd  of the surface.  

Further reading:

Gastric mucosal atrophy: interobserver consistency using new criteria for classification and grading.

Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994.

Observer variation in the assessment of chronic gastritis according to the Sydney system.

Histopathology of gastroduodenal inflammation: the impact of Helicobacter pylori.  

 

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Gastric Pathology - Home Page   

 

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)


 

 

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