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Site Marker GI PATHOLOGY REPORT CLIA #: 31D1026901 Consulting Pathologist: Reema Jaffar, MD PATIENT DEMOGRAPHICS PATIENT INFORMATION: Patient, Test DOB: 2/22/1965 Gender/Age: M/54 SS#: UN:153874675 PHYSICIAN INFORMATION: Test Physician Test Practice 46 Jackson Drive, Cranford, NJ 07016 866.909.PATH, Fax:9082721478 SPECIMEN INFORMATION: ACCESSION #: TS1900012 PROCEDURE DATE: 5/6/2019 DATE RECEIVED: 5/7/2019 REPORTED 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 in background of antral type gastric mucosa with moderate intestinal metaplasia (Alcian blue stain)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)see comment. Negative for H. pylori, confirmed by immunostain. Negative for dysplasia or malignancy. Comments: The biopsy from the antrum shows focal intraepithelial neoplasia (lowgrade intraepithelial dysplasia/neoplasia), mild chronic inflammation and moderate atrophy (metaplastic intestinal type). The biopsy from the angularis shows mild chronic inflammation and mild atrophy (metaplastic intestinal type). The antral atrophy score (Aas) is 2. The biopsy from the fundus and body shows mild chronic inflammation and moderate atrophy (metaplastic intestinal type). The corpus atrophy 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 (low grade dysplasia), H&E Intestinal metaplasia, H&E BILLING CODES CPT 88305 X 3 88312 X 3 88313 X 3 ICD10 K29.50; K31.89 Date of Procedure: 5/6/2019 ELECTRONICALLY SIGNED OUT BY Pathologist: Reema Jaffar, MD Physician: Test Physician Electronically signed out by: Reema Jaffar, MD 46 Jackson Drive, Cranford, NJ 07016 Tel: 1866909PATH Fax: 9082721478 Page 1 of 1 assessments

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Site Marker

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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