UPMC template for histological evaluation of small intestine allograft biopsies
1A. Fragments of small bowel ( )
2. Architectural distortion...( )Norm( )Indeter( )Mild( )Mod( )Sev 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 7. Mucosal erosion/ulceration..... ..( )YES ( )NO 8. Luminal inflammatory exudate.... .( )YES ( )NO
9. Lamina propria inflammation..... .( )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 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 19. Other findings:
20. Diagnosis categories (Check as many categories as appropriate)
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If you have questions, please email TPIS Administration. |
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