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Reporting of Gastric Biopsies

(Non-Neoplastic Lesions)

Dr Sampurna Roy MD

GI Path Online- Home Page Gastric Pathology - Home Page

August  2015


Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)


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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


To demonstrate specific inclusions (CMV , herpes virus)

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


Notes on reporting of Gastric Biopsies:

1.  Antral and corpus biopsies reported separately

2. Gastritis classified into:



Special- Reactive/chemical,




3. Variables to be graded:    

Chronic inflammation

Neutrophils (sign of activity)


Intestinal metaplasia

4.  Non-graded variables:




Epithelial degeneration
5.  A short summary at the end of the report should include:

Etiology (if known)

Topography (antrum, corpus or  pangastritis)

Morphology (including the variables)       



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.  

GI Path Online- Home Page Gastric Pathology - Home Page   

Normal Histology of Esophagus

An approach to the reporting of esophageal biopsies

Benign tumours and tumour -like conditions of esophagus.

 1. Squamous papilloma of the esophagus

 2.Inflammatory fibroid polyp of the esophagus

 3. Leiomyoma of the esophagus

 4. Granular cell tumour of the esophagus

 5. Esophageal cysts 

 6. Glycogenic acanthosis 

Reporting of esophageal resection specimens

Squamous epithelial dysplasia  including squamous cell carcinoma in-situ of the esophagus

Small cell carcinoma of the esophagus 

Drug related lesions of the gastrointestinal tract.


An outline of the anatomy and normal histology of the  stomach for pathologists.

Reporting of gastric biopsies (non-neoplastic gastric lesions).

Pathology and pathogenesis of peptic ulcer.

Acute Gastritis 

Chronic Gastritis

Helicobacter pylori  associated (TypeB)  Gastritis 

Autoimmune Gastritis (Type A) 

Reactive /Reflux/ Chemical Gastritis (Type C)

Lymphocytic Gastritis

Collagenous Gastritis

Granulomatous Gastritis

Eosinophilic Gastritis

Gastric Xanthoma/ Xanthelasma

Other Non-Neoplastic Gastric Lesions


- Normal Histology of the Large Intestine

- Interpretation of Large Intestinal Biopsies

- Assessment of abnormalities -1 (lumen, surface epithelium, subepithelial zone)

- Assessment of abnormalities - 2  (crypt density , architecture and epithelium)

- Assessment of abnormalities - 3  (changes in the lamina propria,muscularis mucosae and submucosa)

Microscopic/ collagenous colitis ;  

- Pseudo membranous colitis ;

Pathology of Amebic Colitis

- Gross examination of colorectal resection specimens in  non-neoplastic diseases


Pathology of the  Intestinal Polyps

Gross examination of polypectomey specimens

Hyperplastic polyps and serrated adenomas

Juvenile polyp ; Peutz-Jeghers polyp ; Inflammatory fibroid polyp ; Multiple Lymphomatous polyposis ;  Lymphoid polyp 


Pathogens commonly affecting Small Intestine



Cytomegalovirus infection


Hookworm Infection






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Paramyxovirus Infection

Parvovirus B19 Infection



Picornavirus Infection



Pneumococcal Pneumonia

Pneumocystiis Carnii Of Ear

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Pseudomembranous Colitis (Clostridium difficile)



Psittacosis (Ornithosis, Parrot Fever)

Pulmonary Infection

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Q Fever


Rat Bite Fever

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Respiratory syncytial virus infection

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