Diagnosis Wording -- How to formulate final pathology diagnosis ...
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Duodenum and Ampulla: Click sections headings below (in blue) to expand or collapse the content
Diagnostic Headings (i.e. specimen & procedure)
Diagnostic Headings |
CPT Code |
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Duodenum, biopsy: |
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Duodenum, bulb, biopsy: |
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Duodenum, second portion, biopsy: |
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Duodenum and stomach, gastroduodenectomy: |
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Pancreas and duodenum, pancreaticoduodenectomy: |
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Dx. Menu -- Wording of Common Abnormalities
This subsection lists key diagnostic line for the most common diseases in this organ / system. Copy the relevant line(s) by clicking on the button and paste to your report to construct your own report. |
Normal and Inflammatory:
-- No diagnostic abnormality.
-- Moderate non-specific chronic duodenitis, favor reactive.
-- Focal moderate peptic duodenitis with gastric metaplasia and acute inflammation.
-- Active gluten-sensitive enteropathy (Celiac sprue), Marsh-Oberhuber classification 3b.
Infectious:
-- Intestinal Giadiasis with multiple luminal clusters of trophozites.
-- Severe cytomegalovirus esophagitis with mucosal erosion and granulation tissue.
-- Duodenal infection by mycobacterium avium intracellulare in sheet, confirmed by Ziehl - Neelsen stain.
Neoplastic:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
-- Dx text (i.e. this section): font = 05BodyT (i.e. Normal); Style = 05 DxBodyS.
Normal or Reactive / Non-specific
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Clinical scenario: 42-year old woman with reflux. r/o Barrette's.
Duodenum, biopsy:
-- Duodenum bulb with no diagnostic abnormality.
-- No increased intraepithelial lymphocytes, stromal eosinophil or dysplasia.
Slides examined: H&E x 1
CPT code: 88305 x 1
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Clinical scenario: 42-year old woman. r/o Celiac sprue
Dudenum, second part, biopsy:
-- No diagnostic abnormality.
-- No diagnostic features of gluten-sensitive enteropathy (Celiac sprue) are present.
Slides examined: H&E x 1
CPT code: 88305 x 1
Editor's comment:
Although the second line of diagnosis is redundant, it actually helps avoid unnecessary phone calls for "just to be sure" by some clinicians who seem to prefer a narrowly specific answer to their inquiry.
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Clinical scenario: 53-year old man with Barrette's.
Duodenum, biopsy:
-- Diffuse mild nonspecific chronic duodenitis, most likely reactive changes
-- No other histologic abnormality
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Clinical scenario: 25-year old man. follow up for eosinophilic esophagitis
Duodenum, biopsy:
-- Mildly increased intraepithelial lymphocytes (up to 20 per 100 lining enterocytes), favor nonspecific reactive change.
-- No villous architectural distortion, crypt hyperplasia or mucosal eosinophilia.
Slides examined: H&E x 1
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 52-year woman with abdominal pain; r/o Celiac sprue.
Duodenum, second portion, biopsy:
-- Moderate peptic duodenitis with gastric metaplasia and focal acute inflammation.
-- No mucosal erosion, granuloma or glandular dysplasia.
-- No diagnostic features of gluten-sensitive enteropathy (Celiac sprue) in this biopsy.
Slides examined: H&E x X
CPT code: 88305 x 1
Editor's comment:
Although a definite diagnosis is rendered, it's a good practice to answer the specific clinical inquiry.
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Clinical scenario: 52-year woman with abdominal pain; r/o Celiac sprue.
Duodenal bulb, biopsy:
-- Mild peptic duodenitis
-- No mucosal erosion, increased intraepithelial lymphocytes, granuloma or stromal eosinophilia.
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Clinical scenario: 16-year old boy with abdominal pain, weight loss and occasional diarrhea.
Duodenal bulb, biopsy:
-- Consistent with active gluten-sensitive enteropathy (Celiac sprue), Marsh-Oberhuber classification 3b (see Note)
-- No mucosal erosion, granuloma or paracytic organism identified.
Note: The constellation of increased intraepithelial lymphocytes (38 / 100 enterocytes), villous blunting and crypt hyperplasia is consistent with diagnosis of Celiac sprue, probably Marsh-Oberhuber classification 3b. Clinical correlation and tests for endomysial and tissue transglutaminase antibodies are recommended to confirm the histological diagnosis.
Slides examined: H&E x X
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 17-year old boy, r/o Celiac sprue
Duodenum, biopsy:
-- Changes suggestive but not diagnostic of active gluten-sensitive enteropathy (Celiac sprue) (see Note).
-- No mucosal erosion, viral inclusion or parasitic organism identified.
Note: The biopsy shows an apparent increase in intraepithelial lymphocytes and focal villous blunting but the changes are insufficient for the diagnosis of gluten-sensitive enteropathy (celiac sprue), equivalent to Marsh-Oberhuber classification 2. Tests for endomysial and tissue transglutaminase antibodies are necessary for a definitive diagnosis.
Slides examined: H&E x X
CPT code: 88305 x 1
Editor's comment:
Involvement of duodenum by Celiac sprue can be patchy. Absence of typical histologic changes in biopsy does not necessarily exclude the possibility. If there is also such clinical concern, further work-up should be recommended .
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Clinical scenario: 17-year old woman, r/o Celiac
Duodenum, biopsy:
-- Moderate lymphocytic duodenitis, etiology uncertain (see Note).
-- No villous or crypt architecture distortion, mucosal erosion, viral inclusion or parasitic organism identified.
Note: There is an apparent increase in intraepithelial lymphocytes (26 /100 enterocytes) and a mild expansion of lamina propria by mononuclear inflammatory infiltrates. However, characteristic features of gluten-sensitive enteropathy (i.e., Celiac sprue) are not present in this biopsy. It is best categorized as lymphocytic enteritis which is a morphological pattern rather than an etiological diagnosis. Although it is often associated with celiac sprue, it by itself is nonspecific and can be associated with other causes. Clinical correlation and tests for endomysial and tissue transglutaminase antibodies , therefore, are recommended.
Editor's comment:
See Comment in the last example .
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Clinical scenario: 67-year old woman with anemia.
Duodenum, bulb, biopsy:
-- Moderate to severe chronic active duodenitis with focal mucosal erosion, etiology uncertain (see Note).
-- No increased intraepithelial lymphocytes, gastric metaplasia, hemorrhage or dysplasia.
Note: The main differential diagnosis should include chemical injury (esp. drug-induced injury) and pepitic ulcer / peptic duodenitis.
Slides examined: H&E x X
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
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-- Dx text (i.e. this section): font = 05BodyT (i.e. Normal); Style = 05 DxBodyS.
-- Note section below: Font = 07NoteT; Style = 07NoteS;
-- Slide examined and CPT code: Font = 08CPTcodeT
-- Slide examined: Style = 04DxHeadings
-- Editor's comment (heading): Font = 09EditCommtHeadT; Style = 09EditCommentS
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Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
Mucosal eosinophilia is a common finding in a wide variety of conditions. The histologic pattern of eorinophilia of eosinophilic enteritis also overlaps significantly with that of other conditions. A definitive diagnosis of eosinophilic enteritis is often very difficult solely on histologic ground.
Dysplasia (Low- to High-grade)
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Clinical scenario: 73-year old woman. Polyp near amppula. r/o/ maligmancy .
Duodenum, polyp, biopsy:
-- Adenoma in four of seven microscopic fragments.
-- No high-grade epithelial dysplasia or invasive carcinoma.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 32-year old woman with epigastric pain; 1.4 cm nodule on endoscropy.
Duodenum, "nodule", biopsy:
-- Enteric neuroendocrine tumor, grade 1 (2010 WHO Classification), present in all fragments, constituting 75% of the specimen, at least 5 mm.
-- No active inflammation, granuloma or glandular dysplasia *
Note: The diagnosis is confirmed by diffuse positive immunohistochemical stains for chromogranin-A, synaptophysin and CDX2. There is no tumor necrosis. Ki67 activity index is 1%.
Slides examined: H&E x 1
CPT code: 88305 x 1, 88342 x 3
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 73-year old man with white nodule in duodenum.
Duodenal bulb, biopsy:
-- Focal lymphangioectasia, predominantly submucosa.
-- No mucosal erosion, granuloma, inflammation, glandular dysplasia or neoplasm.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
Lymphangioectasia is not an uncommon finding in elderly. It is usually noted as small white nodule(s) on endoscopy. Dysplasia and malignant neoplasm are among the main concerns. Including negative findings of pertinent DDx can help address these concerns.
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Clinical scenario: 23-year old woman with protein-loss enteropathy.
Duodenal bulb, biopsy:
-- Prominent lymphangioectasia.
-- No active inflammation, granuloma, increase intraepithelial lymphocytes or parasites.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
Protein-loss enteropathy in this age group is mainly associated with celiac spru, Crohn's disease, infections (esp., giadia and strongyloidiasis) and lymphangioectasia. Including negative findings of pertinent DDx can help clinical interpretation.
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Clinical scenario: 57-year old man with chronic pancreatitis; 1.1 cm node in duodenum bulb; r/o malignency.
Duodenum bulb, excisional biopsy:
-- Brunner gland hyperplasia consistent with Brunner gland hamartoma (see Note).
-- No mucosal erosion, acute inflammation, gladular dysplasia or carcinoma.
Note: Sections reveal sheet of Brunner glands focally admixed with mucosal glands, Paneth cells and smooth muscle. The hyperplastic glands largely replace lamina propria and submucosa, with entrapped mature adipose tissue. There is no cytological atypia or mitosis.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
Abbass R, Al-Kawas FH. Brunner Gland Hamartoma. Gastroenterology & Hepatology 2008;4(7):473-475.
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Clinical scenario: .
Ampulla, mucosa biopsy:
-- Duodenal and ampullar mucosa with prominent mural disarray, focal fibrosis and reactive changes.
-- No active inflammation, glandular dysplasia (adenoma) or carcinoma.
Ampulla: Dysplasia and Carcinoma
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Clinical scenario: .
Duodenum and proximal pancreas, pancreaticoduodenectomy:
-- Poorly differentiated invasive adenocarcinoma of the ampulla with focal signet-ring cell features ( and )
-- Metastatic carcinoma, at least 1.2 cm measured on slides in nine of sixteen regional lymph nodes with extranodal extension (9/16)
-- Multiple nodule of fat necrosis with degenerative changes
-- No significant histological abnormality in the distal stomach
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Clinical scenario: .
Organ, site, surgical procedure:
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Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.