Reporting of Gastric Biopsies (Non-Neoplastic Lesions)

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- 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 ;

- Pseudomembranous colitis ;

- Pathology of Amebic Colitis ;

- Eosinophilic Gastroenteritis ;

- 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

Inflammatory polyps/ Inflammatory cap polyps / Polypoid mucosal polyps

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

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

Benign tumour and tumour- like lesions

Gastric Lymphoma

Gastric Carcinoid Tumour

Gastrointestinal Stromal Tumour

Gastric Epithelial Dysplasia

Early Gastric Carcinoma

Gross Examination of the Gastrectomy Specimen

Myxoid Tumours of Soft Tissue

Classification of Soft Tissue Tumour

Gross examination of soft tissue specimen

A practical approach to histopathological reporting of soft tissue tumours

Grading of soft tissue tumours

Lipomatous tumours

Neural tumours

Myogenic tumours

Fibroblastic/Myofibroblastic tumours

Myofibroblastic tumours

Fibrohistiocytic tumours

ChondroOsseous tumours

Soft TissueTumours of Uncertain Differentiation

Notochordal Tumour - Chordoma

Extra-adrenal Paraganglioma

Gastrointestinal Stromal Tumour

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.
- H/O intake of drugs (eg 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)

NOTES ON REPORTING OF GASTRIC BIOPSIES:

1. Antral and corpus biopsies reported separately

2. Gastritis classified into:
      Acute
      Chronic
    Special-   Reactive/chemical,
                       Lymphocytic
                       Granulomatous
                       Eosinophilic

3. Variables to be graded:

           Chronic inflammation
           Neutrophils (sign of activity)
           Atrophy
           Intestinal metaplasia

4. Non-graded variables:
                    Haemorrhage
                    Granuloma
                    Erosions
                    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)

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. Gastric mucosal atrophy: interobserver consistency using new criteria for classification and grading.Aliment Pharmacol Ther. 2002 Jul;16(7):1249-59.

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. Histopathology of gastroduodenal inflammation: the impact of Helicobacter pylori. Histopathology . 1995 Jan;26(1):1-15.