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GI Biopsies Reporting Tool

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How to Use

Click the tiles to open a party type section

Choose your part type, micros and any comments

Your report will be built as you click through on the panels to the right

Add a part type to gross dictations

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Immunohistochemistry Table

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Chooose cells of interest	Which block was stained	Choose preferred header

Antibody	Value	Comments

Interpretation:

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Description of new interpretation

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Type your additional interpretation of the stains, if any

Choose your patient age

Generic final diagnoses

SPECIMEN DID NOT SURVIE
NO SPECIMEN IN BOTTLE
NEGATIVE GMS/AFB
NO HP ON GIEMSA
NEG DYSPLASIA OR CARCINOMA

Generic micros commentary

NO GRANULOMAS SEEN
NO GRANULOMAS/VIRUS SEEN
NO ACR OR GVH
NO DYSPLASIA OR CARCINOMA SEEN

Uh Oh! Something doesn't look right.

Duodenum

Part Types

DUO
DUO, BULB
DUO, "ULCER"
DUO, "LESION"
DUO, ___

Diagnoses

NO SIGNIFICANT ABNORMALITIES
SUPERFICIAL BX, NO SIGNIFICANT ABNORMALITIES
CHRONIC + GASTRIC METAPLASIA, NO ACUTE
CHRONIC ACTIVE
FOCAL ACUTE INFLAMMATION
ACUTE EROSIVE DUODENITIS
CHRONIC & FOCAL ACTIVE
CHRONIC ACTIVE w/ GRANULOMAS
CHRONIC ACTIVE W/ GASTRIC METAPLASIA
CELIAC
INCR VILLOUS LYMPHS, NL ARCHIT
VILLOUS BLUNTING, NO ↑ IN IELS
↑ LYMPHS IN VILLOUS TIPS
↑ LP CELLULARITY
↑ LP EOS

Micros

NORMAL
SUPERFICIAL VILLI, NORMAL
CHRONIC + GASTRIC METAPLASIA, NO ACUTE
CHRONIC ACTIVE
FOCAL ACUTE ONLY
ACUTE EROSIVE DUODENITIS
CHRONIC & FOCAL ACTIVE
CHRONIC ACTIVE W/ GRANULOMAS
CHRONIC ACTIVE + GASTRIC METAPLASIA
CELIAC
INCREASED IELS & NORMAL VILLI
SHORT VILLI, NO IELS
↑ LYMPHS IN TIPS ONLY
↑ LP CELLULARITY
↑ LP EOS

Stomach

STO
STO, ANTRUM
STO, BODY
STO, A & B
STO, CARDIA
STO, FUNUDS
STO, PYLORUS
STO "LESION"
STO, ____

Final Diagnosis

NSA & NEGATIVE HP
NEG ANTRODUODENUM & NEG HP

MILD CHRONIC GASTRITIS
MILD CHRONIC W/ BASAL EOS
↑ LAMINA PROPRIA EOSINOPHILS

FOCALLY ENCHANCED GASTRITIS
CHRONIC GASTRITIS -HP
CHRONIC GASTRITIS +HP
CHRONIC GASTRITIS + INCR EOS, -HP
FOCAL EROSIVE GASTRITIS, -HP

CHRONIC ACTIVE GASTRITIS -HP
CHRONIC ACTIVE GASTRITIS +HP
CHRONIC FOCAL ACTIVE GASTRITIS -HP
CHRONIC FOCAL ACTIVE GASTRITIS +HP
CHRONIC ACTIVE GASTRITIS + ULCER
CHRONIC ACTIVE GASTRITIS + GRANS

FUNDIC GLAND POLYP
REACTIVE GASTROPATHY
ATROPHIC GASTRITIS
COLLAGENOUS GASTRITIS
NEG ANTRO-DUODENUM & NEG HP

Micros

NORMAL (SHIFT CLICK TO GROUP PARTS) NORMAL ANTRO-DUODENAL TRANSITION

MILD CHRONIC GASTRITIS
↑ BASAL EOS
↑ LP EOS

FOCALLY ENHANCED GASTRITIS
CHRONIC GASTRITIS, NO HP
CHRONIC GASTRITIS, YES HP
CHRONIC GASTRITIS + ↑ EOS, NO HP
FOCAL EROSIVE GASTRITIS

CAG, NO HP
CAG, YES HP
CHR & FOCAL AG, NO HP
CHR & FOCAL AG, YES HP
CAG + ULCER, NO HP
CAG + GRANULOMAS, NO HP

FUNDIC GLAND POLYP
REACTIVE GASTROPATHY
ATROPHIC GASTRITIS
COLLAGENOUS GASTRITIS
IRON-SALT GASTRITIS

Esophagus

Part Types

ESO
ESO, DISTAL
ESO, MID
ESO, PROX
ESO, @__CM
ESO "LESION"
GEJ

Final Diagnoses

NO SIGNIFICANT ABNORMALITIES
SUPERFICIAL, NO SIGNIFICANT ABNORMALITIES

GEJ, NSA
GEJ W/ IM
GEJ W/ GERD CHANGES

MILD REACTIVE ESOPH, NO IEE
REACTIVE ESOPH, NO IEE
REACTIVE W/ SUBMUCOSAL FIBROSIS (CROHN)
REACTIVE EOSPH + LYMPHS

MILD REACTIVE + FEW EOS (GERD)
REACTIVE + EOS (GERD)
EOSINOPHILIC ESOPHAGITIS

ACTIVE ESOPHAGITIS, -FUNGUS
ACTIVE ESOPHAGITIS, + FUNGUS
FUNGAL ESOPHAGITIS, NO NEUTS
ACUTE EROSIVE ESOPHAGITIS
GRANULATION TISSUE POLYP

Micros

NORMAL, 1 SITE
SUPERFICIAL NORMAL, 1 SITE
NORMAL, MULTI SITES
SUPERFICIAL NORMAL, MULTI SITES

NORMAL GEJ, NO IM
GEJ, W/ GERD, NO IM
GEJ, YES IM; NO DYS OR CA

MILD RE NO EOS, 1 SITE
RE, 1 SITE
RE, MULTI SITES
RE WITH LYMPHS, 1 SITE
RE + LYMPHS, FIBROSIS, 1 SITE
MILD RE+EOS, 1 SITE
RE+EOS, 1 SITE
RE+EOS, MULTI SITES
EE, 1 SITE
EE, MULTI SITES
ACTIVE,NO CANDIDA
ACTIVE W CANDIDA
CANDIDA ONLY
ACUTE EROSIVE, NO FUNGUS
GRANULATION TISSUE ONLY, NO FUNGUS

Small Intestine

Part Types

TI
JEJUNUM
ILEUM
ANASTOMOSIS SITE
POUCH
ILEUM LESION
ILEO-CECAL VALVE
SMALL INTESTINE (UNSPECIFIED)

Final Diagnoses

NO SIGNIFICANT ABNORMALITIES
SUPERFICIAL, NO SIGNIFICANT ABNORMALITIES
FOCAL ACUTE INFLAMMATION
INCREASED LP CELLULARITY
INCREASED LP EOS
CHRONIC ACTIVE ILEITIS
CHRONIC FOCAL ACTIVE ILEITIS
CHRONIC ACTIVE WITH GRANULOMAS
ACTIVE ILEITIS WITH ULCER
GRANULOMATOUS INFLAMMATION

Micros

NORMAL
SUPERFICIAL, NORMAL
FOCAL ACUTE INFLAMMATION
INCREASED LP CELLULARITY
INCREASED LP EOS
CHRONIC AND ACTIVE
CHRONIC AND FOCAL ACTIVE
CHRONIC AND ACTIVE W/ GRANULOMAS
CAI W/ ULCER
GRANULOMATOUS INFLAMMATION

Colon and Rectum

Part Types

COLON, CECUM
COLON, ASCENDING
COLON, CECUM AND ASCENDING
COLON, RIGHT
COLON, TRANSVERSE
COLON, DESCENDING
COLON, TV AND DESCENDING
COLON, LEFT
COLON, RECTOSIGMOID
COLON, SIGMOID
COLON, RANDOM
COLON, @ ___ CM
COLON "LESION"
RECTUM
RECTUM "LESION"

Final Diagnoses

NO SIGNIFICANT ABNORMALITIES

LYMPHOID AGGREGATE
GLAND ARCHITECTURAL CHANGES
MELANOSIS COLI
LYMPHOCYTIC COLITIS, NORMAL COLLAGEN
COLLAGENOUS COLITIS
FOCAL ACUTE INFLAMMATION
CHRONIC FOCAL ACTIVE COLITIS
CHRONIC ACTIVE COLITIS
CHRONIC ACTIVE WITH GRANULOMAS
GRANULOMATOUS INFLAMMATION
ACTIVE COLITIS WITH ULCER
INCREASED LAMINA PROPRIA EOSINOPHILS
GRANULATION TISSUE POLYP

Adenomatous lesions

HP
TUBULAR ADENOMA
TA WITH HIGH GRADE DYS
SESSILE SERRATED ADENOMA
SSA WITH HIGH GRADE DYS
TRAD SERRATED ADENOMA

Rectum

JUVENILE POLYP
INCIPIENT JUVENILE POLYP
NEGATIVE FOR HIRSCHSPRUNGS
POSITIVE FOR HIRSCHSPRUNGS
SRUS/PROLAPSE

NORMAL, 1 SITE
NORMAL, MULTI SITES

LYMPHOID AGGREGATE
LYMPHOID AGGREGATES MULTI SITES
MILD ARCH CHANGES
MELANOSIS COLI, 1 SITE
MELANOSIS COLI, MULTI SITES
LYMPHOCYTIC COLITIS
COLLAGENOUS COLITIS, 1 SITE
COLLAGENOUS COLITIS, MULTI SITES
FOCAL ACUTE, 1 SITE
CHRONIC & FOCAL ACUTE, 1 SITE
CHRONIC & ACTIVE, 1 SITE
CHRONIC & ACTIVE, MULTI SITES
SEVERE CAC, 1 SITE
SEVERE CAC W GRANULOMAS, 1 SITE
SEVERE CAC, MULTI SITES
SEVERE CAC W GRANULOMAS, MULTI SITES
GRANULOMAS ONLY, 1 SITE
GRANULOMAS ONLY, MULTI SITES
INCREASED LP EOS, 1 SITE
GRANUATION TISSUE POLYP

Adenomatous lesions

HP, 1 SITE
HP, MULTI SITES
TA, 1 SITE
TA, MULTI SITES
TA w DYSP, 1 SITE
TA w DYSP, MULTI SITES
SSA, 1 SITE
SSA, MULTI SITES
SSA w DYSP, 1 SITE
SSA w DYSP, MULTI SITES
TSA, 1 SITE
TSA, MULTI SITES

Rectum

NORMAL RECTUM
JUVENILE POLYP
INCIPIENT JUVENILE POLYP
NOT HIRSCHSPRUNG
YES HIRSCHSPRUNG
SRUS/PROLAPSE

Comments

General Case Comments

CASE D/W

Upper GI comments

Duodenum comments

TYPICAL CELIAC
CELIAC SEROLOGY, NOT HISTOLOGY
INCREASED IELS, NL VILLOUS MORPHOLOGY
INCREASED IELS, <6 MONTHS OLD
FOCAL DUODENUM INFLAMMATION
EROSIVE DUODENITIS
MILD VILLOUS BLUNTING, NO IELS
TUFTED ENTEROPATHY
GASTRIC FOVEOLAR METAPLASIA (INACTIVE)

Esophagus comments

EE VS. REFLUX
TYPICAL EE PATTERN
RESIDUAL EE W/ SUPERIMPOSED GERD
EROSIVE ESOPHAGITIS WITH NEUTS (NO FUNGUS)

Stomach comments

GASTRIC LP EOS + GASTRITIS
REACTIVE GASTROPATHY
FOCALLY ENHANCED GASTRITIS W/ REFERENCE
INCR GASTRIC EOS + CHRONIC INFLAMMATION
COLLAGENOUS GASTRITIS
IRON-SALT GASTRITIS
FOCAL EROSIVE GASTRITIS

Lower GI comments

Colon/Bowel comments

IBD, NONSPECIFIC
IBD, SUGGESTING CROHN
IBD W/ GRANULOMAS = CROHN
IBD-LIKE, YOUNG CHILD
MELANOSIS COLI
JUVENILE POLYPOSIS?
SSA COMMENT
LYMPHOCYTIC COLITIS
FOCAL ACUTE INFLAMMATION, ISOLATED
NEGATIVE FOR GVHD

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