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GI PATHOLOGY REPORT

CLIA #: 31D1026901

Consulting Pathologist: Reema Jaffar, MD

PATIENT DEMOGRAPHICS

PATIENT INFORMATION:Patient, TestDOB: 2/22/1965Gender/Age: M/54SS#: UN:153874675

PHYSICIAN INFORMATION:Test PhysicianTest Practice46 Jackson Drive, Cranford, NJ 07016866.909.PATH, Fax:9082721478

SPECIMEN INFORMATION:ACCESSION #: TS1900012PROCEDURE DATE: 5/6/2019DATE RECEIVED: 5/7/2019REPORTED ON: 5/8/2019

CLINICAL INFORMATION

CLINICAL HISTORY: Nausea, Gastritis, need gastritis "OLGA scoring"

FINAL DIAGNOSIS

A: STOMACH, ANTRUM, BIOPSY:Focal Intraepithelial neoplasia (low grade intraepithelial neoplasia/dysplasia) arising inbackground of antral type gastric mucosa with moderate intestinal metaplasia (Alcian bluestain)see comment.Negative for H. pylori, confirmed by immunostain.Negative for high grade dysplasia or malignancy.

B: STOMACH, ANGULARIS, BIOPSY:Antral type gastric mucosa with mild intestinal metaplasia (Alcian blue stain)see comment.Negative for H. pylori, confirmed by immunostain.Negative for dysplasia or malignancy.

C: STOMACH, FUNDUS, BIOPSY:Fundic type gastric mucosa with moderate intestinal metaplasia (Alcian blue stain)seecomment.Negative for H. pylori, confirmed by immunostain.Negative for dysplasia or malignancy.

Comments:The biopsy from the antrum shows focal intraepithelial neoplasia (lowgrade intraepithelialdysplasia/neoplasia), mildchronic inflammation and moderate atrophy (metaplastic intestinal type). The biopsy fromthe angularis shows mildchronic inflammation and mild atrophy (metaplastic intestinal type). The antral atrophyscore (Aas) is 2. The biopsy fromthe fundus and body shows mild chronic inflammation and moderate atrophy (metaplasticintestinal type). The corpusatrophy score (Cas) is 2.

Overall, the biopsies exhibit OLGA stage III gastritis secondary to remote history of H.pylori gastritis.This case has been seen at our intradepartmental QA conference.

REFERENCE: Digestive and Liver Disease 40 (2008) 650658.

SITE MAP

Intraepithelial neoplasia (lowgrade dysplasia), H&E Intestinal metaplasia, H&E

BILLING CODESCPT88305 X 388312 X 388313 X 3

ICD10K29.50; K31.89Date of Procedure: 5/6/2019

ELECTRONICALLY SIGNED OUT BY

Pathologist:

Reema Jaffar, MD

Physician: Test Physician Electronically signed out by: Reema Jaffar, MD46 Jackson Drive, Cranford, NJ 07016 Tel: 1866909PATH Fax: 9082721478

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