UPMC template for histological evaluation of small intestine allograft biopsies

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-B
6A. Number of inflammatory cells/crypt ( )2-4 ( )5-10 ( )>10
6B. Type...( )mononuclear cells ( )neutrophils ( )eosinophils

7. Mucosal erosion/ulceration..... ..( )YES ( )NO

8. Luminal inflammatory exudate.... .( )YES ( )NO

9. Lamina propria inflammation..... .( )YES ( )NO
if YES, check 9A-C
9A. Severity ( )Mild ( )Mod ( )Sev
9B. Type ( )mononuclear cells ( )neutrophils ( )eosinophils
9C. Subendothelial "endotheliitis"..( )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. Muscular wall necrosis ( )YES ( )NO

14. Lymphoid aggregates.....( )

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
18A. If YES, specify: ( )CMV ( )HSV ( )EBV ( )Adenovirus ( )Candida ( )Others

19. Other findings:

20. Diagnosis categories (Check as many categories as appropriate)
( )No pathologic change
( )Preservation injury
( )Non-specific inflammation
( )Ischemic change
( )Regenerative changes
( )Acute rejection......( )Indeter( )Mild( )Mod( )Sev
(check if follow-up)..( )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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