You will receive duodenal biopsies to rule out celiac disease/sprue; biopsies of ampullary lesions (mostly adenomas); and terminal ileum biopsies to rule out IBD. On some ERCP procedures, they may get a biopsy of the bile duct (often at the same time they get a brushing, so check for the presence of a cytology specimen). Also, in any small bowel biopsy, make sure to look for bugs.
Fresh Handling/Grossing In/Sample DictationEdit
- The specimen may be received already fixed and oriented (mucosal side up) on a piece of filter paper, gelfoam, plastic mesh, or other substrate. If so, do not remove it from the substrate as the specimen has already been positioned in the proper anatomic orientation. It is essential for the specimen to be oriented on edge.
- Otherwise, see Endoscopic biopsies general
Review and SignoutEdit
The lab should cut multiple levels of each specimen (usually three) and each level may contain several profiles of the tissue. Be sure to look at all of them!
1. Small bowel, biopsy:
2. Duodenum, biopsy: (Call it duodenum if you see Brunner's glands.)
- -Small bowel mucosa with no specific pathologic change.
- -Duodenal mucosa with no specific pathologic change.
- -Duodenal mucosa with (mild, moderate, severe) chronic duodenitis.
- -Small bowel mucosa with (mild, moderate, severe) chronic inflammation without villous blunting or intraepithelial lymphocytosis.
- -Small bowel mucosa with (mild, moderate, severe) chronic inflammation, villous blunting and intraepithelial lymphocytosis. (Can then add a comment discussing celiac disease.)
Helpful hints in looking for microorganisms in small biopsies:
- Giardia lamblia - usually seen in the mucin adjacent to the epithelium of the villi. Rarely invades into the mucosa itself. May be associated with villous atrophy and/or nodular lymphoid hyperplasia, but usually mucosa appears normal. Seen well if carefully sought after with the H&E stain; however, some find Trichrome and Giemsa stains helpful in this regard.
- Whipple's disease - the Whipple's bacilli are best detected with the PAS stain in foamy macrophages in the lamina propria. These bacilli are not acid-fast.
- Mycobacterium Avium Intracellulare (see almost always in AIDS patients) - also seen in macrophages in the lamina propria. These bacilli also stain with PAS (thus "pseudo-Whipple's disease"), but are also acid-fast positive.
- Cryptosporidium - seen as small (2-5µm) round, slightly basophilic structures attached to the microvillar border. Usually associated with minimal inflammatory response. They do not invade the intestinal mucosa. Special stains such as Giemsa or a modification of the Kinyoun-Acid-Fast stain may be helpful. One must be careful not to confuse these organisms with small mucin granules.
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