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Small bowel, Non-Tumor

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IntroductionEdit

Most commonly received in the morning for either trauma or ischemic injury. Another common specimen in this category is an ostomy site “takedown”. The questions to be answered are:

  1. Why was the procedure done?
  2. Is there any pathology?

Fresh HandlingEdit

Often these specimens are not oriented.

  1. Measure the length and diameter of the specimen, as well as any staple lines.
  2. If several fragments are received in the same specimen, identify them as fragment #1, #2, etc, and describe each of them separately.
  3. For trauma bowel, documentation is essential (theoretically the case could become evidence in a trial), so make sure to take gross photographs of all segments received.
  4. Search for areas of perforation or other lesions, measure them and state the distance to the margins.
  5. Describe the serosa (smooth and glistening, or ragged and erythematous, bowel-to-bowel adhesions, etc.).
  6. Open the specimen, rinse the mucosal surface with saline, and describe any lesions.

The ostomy takedown specimens may consist of an anastomotic donut (a metallic device that looks like a pin with a disc on top) with or without attached tissue. On other occasions, there will be a very short segment of bowel with attached skin (the stoma site).

Grossing InEdit

Gross documentation can be more relevant than the microscopic description in these cases. Make sure to document all the pieces, areas of perforation, presence of adhesions, involvement of margins and areas of normal mucosa in the dictation.

  1. Shave margins and 1-2 representative sections of the involved (edematous, hemorrhagic, thinned) wall are enough for ischemic lesions. If possible, take a section of involved regions in transition to uninvolved mucosa. A representative section of grossly normal mucosa may be helpful to identify underlying disease (atherosclerotic emboli, vasculitis…).
  2. For trauma cases, take shave margins and then representative sections of the perforated or hemorrhagic areas.
  3. For ostomy sites submit the tissue attached to the anastomotic device, if any. If there is skin, submit a longitudinal section that includes bowel mucosa and skin. Submit shaved margins if there are any staple lines.

Sample DictationEdit

1. The specimen is received (fresh, in formalin) in a container labeled with the patient's name and medical record number, and designated "(jejunum, ileum, small bowel, …)". It consists of an (unoriented/oriented) segment of small bowel measuring x cm in length and x cm in diameter. The specimen is received stapled at both margins of resection, which measure x and x cm in diameter, respectively. (Or: There is a staple line on one end measuring x cm, the opposite end is received open and measures x cm in diameter. Or: The specimen is received open on borh ends). The external serosal surface is (dull, irregular and focally congested and hemorrhagic, smooth and glistening, shows extensive adhesions…). The serosal surface is inked black and the specimen is opened along its antimesenteric aspect to reveal (describe any lesions such as perforations, pseudomembranes, mucosal tears, ulcers, polyps, etc), located x cm from the stapled end. The bowel wall in this congested area is thinned out, relative to the remaining bowel (this may be a gross sign of ischemic bowel). The remaining mucosal surface is smooth, glistening and grossly unremarkable. Representative sections are submitted as follows:

1A, margin of resection further from area of congestion
1B, margin of resection closer to the area of congestion
1C, 1D, representative sections at area of congestion
1E, representative, longitudinal section of unremarkable bowel

Review and SignoutEdit

Small bowel for traumaEdit

You're just documenting the need to take this bowel out (transmural inflammation, perforation, ischemia), and mention the margins.

  1. Ileum, segmental resection:
Small bowel with transmural performation and associated serositis, resection margins viable.
Small bowel with transmural ischemic necrosis, resection margins viable.

J-pouch, ostomy site, etc.Edit

  1. J-pouch, revision:
  2. Ostomy site, revision:
Small bowel, consistent with J-pouch.
Skin and small bowel, consistent with ostomy site.

Return to Gastrointestinal Grossing

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