Contributed by Randall G. Lee, M.D.
PATIENT HISTORY:
Per referral report, the patient is a elderly male with a pre-op diagnosis of colon polyp, esophageal nodularity. R/O Helicobacter. Review of outside material.

Final Diagnosis (Case 4)

PARTS 1 AND 2:
SMALL BOWEL, DUODENUM, ENDOSCOPIC BIOPSY OF PAPILLA AND FOLD OPPOSITE PAPILLA -
  1. CHRONIC DUODENITIS WITH MILD INFLAMMATORY ACTIVITY, PROMINENT REGENERATIVE MUCOSAL CHANGES, AND REACTIVE EPITHELIAL ATYPIA.
  2. NO EVIDENCE OF ADENOMA OR MALIGNANCY.

    PARTS 3 AND 4:
    STOMACH, ANTRUM AND CARDIA, ENDOSCOPIC BIOPSY -

      MILD CHRONIC ACTIVE GASTRITIS WITH HELICOBACTER ORGANISMS IDENTIFIED.

      PART 5:
      ESOPHAGUS, ENDOSCOPIC BIOPSY -

        MILD ACTIVE ESOPHAGITIS CONSISTENT WITH REFLUX DISEASE.

        PARTS 6 AND 7:
        LARGE BOWEL, COLON AT 40.0 CM. AND RECTUM, ENDOSCOPIC BIOPSIES -

        1. CAUTERIZED COLONIC MUCOSA SHOWING FEATURES OF HYPERPLASTIC POLYPS.
        2. NO EVIDENCE OF ADENOMA OR MALIGNANCY.

        Comment:
        The duodenal biopsies show evidence of previous mucosal injury with regenerative changes. These changes are not felt to be dysplastic or adenomatous in nature based on the lack of increase in glandular profiles, the concomitant presence of active inflammatory infiltrate, and the maturation towards the luminal surface. These findings are all in favor of a reactive rather than neoplastic proliferation.

        Previous Biopsies on this Patient:
        None

        TPIS Related Resources:
        None.

        Gross Description - Case 4

        The specimen consists of eight (8) consult slides with an accompanying surgical pathology report.

        Microscopic Description - Case 4

        (8 HE)
        Microscopic examination substantiates the above diagnosis.

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