| 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 |
