Normal and Nearly Normal:

-- 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.   

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Clinical scenario:  .       

Small intestine, biopsy:     

-- No diagnostic abnormality. 

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:  .       

Small intestine, segmental resection:     

-- No diagnostic abnormality. 

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:  .       

Small intestine, further designated as 'ulcer', biopsy:     

-- No diagnostic abnormality (see Note).  

Slides examined:  H&E x  1 

CPT code:         88305 x 1 

Editor's comment:

It is prudent to correlate histologic changes with clinical / endoscopic findings. When discrepancy exists, a short note to propose possible reasons and / or solution is highly desired.    

=============

Clinical scenario:  .       

Small intestine, segmental resection:     

-- Submucosal vascular congestion. 

-- No ischemic necrosis, serosal fibrosis (adhesion) or enteritis.

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  .       

Organ, site, surgical procedure:     

-- No diagnostic abnormality (see Note).

Note: Specimen is submitted entirely for histologic examination.  Multiple additional levels of the tissue blocks are examined.

Slides examined:   H&E   x  4

CPT code:        88305 x  1

=============

Clinical scenario:  .       

Small intestine, biopsy:     

-- Severe erosive enteritis, etiology uncertain (see Note). 

-- No ischemia, glandular dysplasia or definite viral cytopathic changes. 

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:  .       

Small intestine, biopsy:     

-- Markedly increased epithelial ring-form of mitotic figures and apoptosis, consistent with chemical toxicity by antimitotic alkaloids (see Note). 

-- No crypt architectural change, inflammation or glandular dysplasia. 

-- No mucosal erosion, viral cytopathic change or dysplasia. 

Slides examined:  H&E x  3 

CPT code:          8305 x  1 

  

=============

Clinical scenario:       

Terminal ileum, biopsy:      

-- Patchy active chronic ileitis with mucosal ulceration, consistent with active Crohn's enteritis. 

-- No viral cytopathic changes, granuloma, glandular dysplasia or carcinoma. 

-- Active Crohn's enteritis with mucosal ulceration and inflammatory fistulas. 

Slides examined:   H&E   x  27

CPT code:        88309 x  1

=============

Clinical scenario:  34-year old man, Hx/ IBD       

Terminal ileum, biopsy:       

-- Patchy active chronic ileitis with mucosal ulceration, consistent with active Crohn's enteritis.

-- No glandular dysplasia.

Slides examined:   H&E   x  3

CPT code:        88305 x  1

=============

Clinical scenario:         

Terminal ileum, biopsy:       

-- Active Crohn's enteritis with mucosal ulceration and inflammatory fistulas.

-- No glandular dysplasia.

Slides examined:   H&E   x  3

CPT code:        88305 x  1

   

=============

Clinical scenario:  A pre-term infant with feeding intolerance and abdominal distension.        

Small intestine, segmental resection:       

-- Diffuse / segmental necrotizing enteritis (see Note)

-- Both end margins are viable and free of inflammation

Note:  Sections reveal patchy areas of mucosal ischemia/necrosis.  The ischemia appears limited to the mucosa.  No transmural necrosis is identified.   Pneumatosis intestinalis is also present.  There is no perforation.  Ganglion cells are easily identified.  In the setting of a preterm infant with feeding intolerance, abdominal distension, pneumatosis, and characteristic radiographic findings, the histologic pattern of injury seen is consistent with necrotizing enterocolitis. 

Slides examined:   H&E   x  27

CPT code:        88309 x  1

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Clinical scenario:  .       

Small intestine, segmental resection:     

-- Focal prominent mural (predominantly submucosal hemorrhage) and vascular congestion. 

-- No ischemic necrosis or active enteritis is identified. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 x __ 

=============

Clinical scenario:  56-year old history of segmental colectomy         

Small intestine, segmental :     

-- Global severe hemorrhagic bowel infarction, most likely secondary to venous outflow obstruction

-- No serosal fibrosis, occlusive vasculopathy, vasculitis or thrombosis of large mesenteric vessels

-- No viable component is present at resection ends/margins

Slides examined:   H&E   x  8

CPT code:        88305 x  1

=============

Clinical scenario:  .       

Small intestine, segmental resection:     

-- Segmental severe ischemic enteritis with transmural necrosis. 

-- No vascular thrombosis is identified. 

-- The proximal and distal end margins are free of ischemic enteritis. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  .       

Small intestine, segmental resection:     

-- Diffuse and extensive mural coagulative necrosis consistent with ischemic enteritis. 

-- Ischemic enteritis present in end margins of both segments. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 x __ 

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Small intestine, segmental resection:     

-- Severe ischemic enteritis with segmental infarction, hemorrhagic-type (secondary to vascular outflow obstruction). 

-- The proximal and distal resection margins are viable and free of ischemic changes. 

-- No definite perforation is identified. 

-- No significant atherosclerotic vascular change or vascular occlusion is identified. 

-- One small benign reactive lymph node. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  .       

Small intestine, segmental resection:     

-- Segmental severe congestive and hemorrhagic enteritis, transmural, consistent with vascular outflow obstruction secondary to bowel strangulation. 

-- Proximal and distal margins appear to be viable and free of hemorrhage. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  .       

Small intestine, segmental resection:     

-- Diffuse acute necrotizing enteritis with multiple vascular thrombosis focally transmural with perforation, probably secondary to ischemia. 

-- Diffuse marked acute serositis with fibrosis. 

-- The proximal and distal resection margins are involved by the necrotizing enteritis. 

-- No occlusive vasculopathy or vascular thrombosis in the mesenteric vessels. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  .       

Small intestine, segmental resection:     

-- Focal prominent submucosal and muscularis propria hemorrhage and extramural hyalinized fibrosis consistent with clinical history of incarceration. 

-- No definite ischemic necrosis or infarction identified. 

-- The proximal and distal resection margins are unremarkable. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  .       

Small intestine, segmental resection:     

-- Diffuse segmental acute ischemic enteritis, largely confined in mucosa and focally in submucosa, most likely secondary to incarceration in hernia sac. 

-- No perforation or neoplasia is identified. 

-- The ischemic enteritis extends to both proximal and distal resection margins. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 x __ 

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.      

=============

Clinical scenario:  .       

Small intestine, segmental resection:     

-- Multifocal prominent reactive serositis with marked fibrosis consistent with gross finding of adhesion. 

-- No mucosal erosion, chronic or acute inflammation, ischemia or perforation. 

-- Two benign reactive lymph nodes (0/2). 

Slides examined:  H&E x  9 

CPT code:         88305 x __, 88307 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:  .       

Small intestine, segmental resection:     

-- Segmental exuberant fibrinoid serositis with granulation tissue and prominent fibrosis.  (up to 5 mm in thickness), consistent with adhesion. 

-- Intact enterocolonic anastomosis. 

-- No mucosal ischemic necrosis, ulceration or neoplasia. 

-- The proximal and distal resection margins appear to be free of inflammation or significant serositis. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  .       

Small intestine, segmental resection:     

-- Focal marked acute serositis with fibrosis (adhesion) most likely secondary to adjacent perforated colonic diverticulitis. 

-- No ischemic infarct, glandular dysplasia or neoplasia. 

Slides examined:  H&E x  __  Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  .       

Small intestine, segmental resection:     

-- Multifocal marked serosal fibrosis consistent with adhesions. 

-- Focal mucosal chronic ischemic change and vascular ectasia suggestive of venous outflow obstruction, probably secondary to adhesion. 

-- No definitive bowel infarction is identified. 

-- The proximal and distal resections margins are viable and free of inflammation. 

Slides examined:  H&E x  __ 

CPT code:           88304 x __, 88305 x __, 88307 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:  58-year old man s/p J-pouch; r/o pouchitis.        

Ileal pouch, afferent segment, biopsy:         

-- Focal minimal acute superficial inflammation with possible erosion, prominent lymphoid aggregate and a well formed epithelioid granuloma, PA score = 6 (see Note). 

-- No viral cytopathic changes, ischemia or glandular dysplasia. 

Note: It is generally accepted that a diagnosis of pouchitis should be based on the combination of clinical, endoscopic and histological findings. Patient's history of "Crohn's disease, s/p J-pouch" is noted in his EMR. The histological assessment provided here only indicates the severity of changes in the biopsy specimen although a recurrent Crohn's disease is favored. 

Pouchitis Activity Score (Heuschen UA at al.)     

Polymorphonuclear infiltration: 0-1 out of 3       

Ulcerations or erosions: 0-1 out of 3

Mononuclear infiltration: 2 out of 3

Villous atrophy: 3 out of 3       

Total histological score: 6 out of 9

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

More than one scoring schema can be found in the literature. It's largely of personal or institutional preference which one to use. But it would be very helpful to be consistent and include a reference of the scoring system. Although the pouchitis disease activity index (PDAI) proposed by Steinhart and colleagues is simpler, it gives a combined diagnostic cut-off which may mislead to a narrower DDx.

References:  A Hillary Steinhart, Ofer Ben-Bassat: Pouchitis: A Practical Guide. Frontline Gastroenterol. 2013;4(3):198-204.

=============

Clinical scenario:  58-year old man s/p J-pouch; r/o pouchitis.       

Ileal pouch-anal anastomosis, biopsy:     

-- Diffuse moderate inflammation with focal mucosal erosion, Pouchitis Activity Score = 7 out of 9 (see note). 

-- Focal granulation tissue formation. 

-- Squamous-glandular junction mucosa with active acute inflammation. 

-- No ischemia, viral cytopathic change, granuloma or glandular dysplasia. 

Note: The patient's history of of "Crohn's disease", s/p j-pouch is noted. It is generally accepted that a diagnosis of pouchitis should be based on the combination of clinical, endoscopic and histological findings. The histological assessment provided here only indicates the severity of changes in the biopsy specimen. 

Reference: Heuschen UA, et al.: Diagnosing pouchitis: comparative validation of two scoring systems in routine follow-up. Dis Colon Rectum. 2002;45(6):776-86.

Slides examined:   H&E   x  3

CPT code:        88305 x  1

Editor's comment:

The ileal pouch-anal anastomosis (IPAA) is also known as an ileo-anal pouch, or sometimes referred to as a j-pouch, s-pouch, w-pouch or an internal pouch. More than one scoring schema can be found in the literature. It's largely of personal or institutional preference which one to use. But it would be very helpful to be consistent and include a reference of the scoring system. Although the pouchitis disease activity index (PDAI) proposed by Steinhart and colleagues is simpler, it does not stratify changes well. It gives a combined diagnostic cut-off which may mislead to a narrower differential diagnoses.  Please visit Essential Pathology - Grading Schema for the scoring system. 

References:  A Hillary Steinhart, Ofer Ben-Bassat: Pouchitis: A Practical Guide. Frontline Gastroenterol. 2013;4(3):198-204.

=============

Clinical scenario:    

Terminal ileum and right colon, segmental ileocolectomy:     

Distal ileum

-- Enteric neuroendocrine tumor, grade 2 (2010 WHO Classification), focally transmural with extensive angiovascular invasion (see Tumor Synopsis). 

-- Small possible submucosal lipomas of the ileocecal  valve. 

-- No significant histological abnormality in the uninvolved ileal mucosa. 

Appendix

-- No significant histological abnormality.   

Right colon 

-- One small tubular adenoma (2 mm measured on slide) at the distal resection margin.

-- The remaining uninvolved  colonic mucosa is unremarkable.

-- No neuroendocrine tumor is identified. 

Mesenteric lymph node, excision

-- Metastatic  neuroendocrine tumor, grade 2 (2010 WHO Classification), 2.2 cm in greatest dimension, in two of two lymph nodes (2/2), with focal extracapsular  extension. 

Slides examined:   H&E   x  27

CPT code:        88309 x  1

Editor's comment:

This example include typical structural components and format that are used widely -- Diagnosis Heading, Main diagnosis, applicable Note or Comment (e.g. stain results), Slides examined and CPT codes. For diagnosis with complex attributes (e.g. of resected malignant tumor), a synoptic report  (or "Checklis") must be included to comply with ACoS mandates. To prepare "Synoptic Report" with an on-line tool, go to  Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.

=============

Clinical scenario:  .       

Small intestine, segmental resection:     

-- A small hyperplastic polyp. 

-- Focal mucosal reactive changes. 

-- No active inflammation, diverticulitum ischemia or epithelial dysplasia.. 

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:  .       

Small intestine, segmental resection:     

-- Gastrointestinal stromal tumor (GIST) transmural extending to muscularis mucosa with predominant extramural growth (see Tumor Synopsis)

--- Focal mucosal erosion with reparative changes associated with the tumor. 

-- Extensive serosal fibrosis with bowel adhesion focally associated with the tumor. 

-- No segmental bowel infarction is identified. 

Slides examined:  H&E x  9 

CPT code:         88307 x 1 

Editor's comment:

This example include typical structural components and format that are used widely -- Diagnosis Heading, Main diagnosis, applicable Note or Comment (e.g. stain results), Slides examined and CPT codes. For diagnosis with complex attributes (e.g. of resected malignant tumor), a synoptic report  (or "Checklis") must be included to comply with ACoS mandates. To prepare "Synoptic Report" with an on-line tool, go to Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.

=============

Clinical scenario:  .       

Small intestine, segmental resection:     

-- Diffuse intestinal angiomatosis with transmural involvement and focal mucosal erosion, consistent with Kaposiform hemangioendothelioma. 

-- No infarction, significant microvascular thrombosis. 

-- The proximal and distal resection margins of the longer segment as well as the stapled linear margin from the second smaller segment are free of angiomatous lesions. 

-- Four reactive lymph nodes negative for malignancy. 

Slides examined:  H&E x  19 

CPT code:         88307 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.    

=============

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.