Medical Pathology Report Form

Basic Report Information

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Clinical Data

Gross Description

Microscopic Description

Diagnosis

<ul><li class="ql-align-justify">Gastric mucosa showing focal erosion and moderate infiltration by lymphocytes and plasma cells. Some neutrophils are seen infiltrating glands thus indicating activity. H. pylori characteristic forms are seen colonizing glands. No evidence of intestinal metaplasia, atypia or malignancy.</li><li class="ql-align-justify">Duodenal biopsy shows preserved villous architecture with normal villous height–crypt depth ratio, intact surface epithelium, and no increase in intraepithelial lymphocytes. There is no evidence of atypia or malignancy.</li><li class="ql-align-justify">Intact colonic mucosa with mild reduction in the number of mucigenic cells and mild infiltration by lymphocytes, plasma cells and neutrophils. However, crypt abscesses are not identified. No evidence of atypical or malignant cells.</li><li class="ql-align-justify">Polypoid lesion formed of hyperplastic intact colonic glands with preserved mucigenic activity. Stroma is fibrotic and shows mild chronic inflammatory reaction composed of lymphocytes and plasma cells. No evidence of specific granulomas. No evidence of crypt abscesses. No evidence of atypia or malignancy.</li></ul>

<h3>1- Stomach, Endoscopic biopsy:</h3><ul><li class="ql-align-justify">H. pylori-associated moderate erosive gastritis with associated moderate inflammatory activity. </li><li class="ql-align-justify">Negative for dysplasia or malignancy. </li></ul><h3>2- Duodenum, Endoscopic biopsy:</h3><ul><li class="ql-align-justify">Normal microscopic appearance. </li><li class="ql-align-justify">Negative for villous atrophy. </li><li class="ql-align-justify">Negative for dysplasia or malignancy. </li></ul><h3>3- Colon, endoscopic biopsy:</h3><ul><li>Mild chronic colitis with minimal inflammatory activity. </li><li>Negative for epithelial dysplasia. </li><li>Negative for malignancy.</li></ul><h3>4- Rectosigmoid, endoscopic polypectomy</h3><ul><li>Hyperplastic polyps, inflamed.</li><li>Negative for malignancy</li></ul>

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