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Template for Allograft Small Intestine Biopsy
(2 H& E)
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1a.Fragments of small bowel( )
1b. Fragments of non-small bowel (if present)( )
2. Architectural distortion( )Norm( ) Indeter( ) Mild ( ) Mod( ) Sev
if distorted, by: ( ) Villous blunting ( ) Mucosal atrophy ( ) Mucosal erosion ( ) Ulceration ( ) Inflammation ( ) Granulation tissue ( ) Regeneration ( )Gland disarray
3. Surface and/or crypt epithelial injury( ) Yes( ) No
4. Surface and/or crypt apoptosis( ) apoptotic bodies/10 crypts
5. Surface and/or crypt mitoses( ) Yes( ) No( ) N/A
6. Surface and/or crypt epithelial inflammation( ) Yes( ) No
if Yes, check 6a-6b
6a. Number of inflammatory cells/crypt( ) 2-4( ) 5-10( ) >10
6b. Type( ) Mononuclear( ) Neutrophils( ) Eosinophils
7. Mucosal erosion/ulceration( ) Yes( ) No
8. Luminal inflammatory infiltrate( ) Yes( ) No
9. Lamina propria inflammation( ) Yes( ) No
if Yes, check 9a-9c
9a. Severity( ) Mild ( ) Mod( ) Sev
9b. Type( ) Mononuclear( ) Neutrophils( ) Eosinophils
9c. Subendothelial "endothiliitis"( ) Yes( ) No
10. Lamina propria fibrosis( )Norm( ) Mild ( ) Mod( ) Sev
11. Granulation tissue( ) Yes( ) No
12. Granulomatous inflammation( ) Yes( ) No
13a. Ischemic necrosis( ) Yes( ) No
13b. Muscle wall necrosis( ) Yes( ) No
14. Lymphoid aggregates( ) Yes( ) No
15. Obliterative arteriopathy( ) Yes( ) No( ) No artery for evaluation
16. Intravascular thrombi( ) Yes( ) No
17. Infiltrates suggestive of PTLD( ) Yes( ) No
18. Infectious agents( ) Yes( ) No
if Yes, specify: ( ) CMV( ) HSV( ) EBV( ) Adenovirus( ) Candida( ) Others
19. Other findings:
20. Diagnostic categories (check as many as appropriate)( ) No pathologic change
( ) Preservation injury
( ) Nonspecific inflammation
( ) Ischemic change
( ) Regenerative changes
( ) Acute rejection( ) Indeter( ) Mild ( ) Mod( ) Sev
check if followup( ) resolving( ) similar( ) worsening
( ) Chronic rejection
( ) Ulceration, cause uncertain
( ) CMV( ) EBV( ) HSV( ) Adenovirus( ) Cryptosporidium
( ) Bacterial overgrowth
( ) Pseudomembranous colitis
( ) PTLD
( ) Vascular thrombosis (specify)
( ) Miscellaneous
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Last Modified: Thu Jun 18 10:14:08 EDT 2009