TISSUES:
A. Proximal Transverse Scar; B. Duodenite; C. 0.5 cm below SCJ; D. 0.5 cm above SCJ; E. 1.5 cm above SCJ.
CLINICAL HISTORY:
Upper GI endoscopy. Proximal transverse, biopsy relative dysplasia. Duodenitis biopsy rule out dysplasia. 0.5 cm below SCJ biopsy rule out Barrett's dysplasia, neoplasm. 0.5 cm above SCJ biopsy rule out Barrett's dysplasia. 1.5 cm above SCJ biopsy rule out Barrett's, dysplasia.
FINAL MICROSCOPIC DIAGNOSIS:
A. Stomach, biopsy
-Minimal chronic inflammation
-Negative for Helicobacter organisms
-Negative for intestinal metaplasia or dysplasia
B. duodenum, biopsy
-Peptic duodenitis
C.gastroesophageal junction, 0.5 cm below SCJ, biopsy
-Reflux changes, junctional mucosa
-Negative for intestinal dysplasia on Alcian blue/PAS stain
-Negative for dysplasia
D. gastroesophageal junction, 0.5 cm above SCJ, biopsy
-Reflux changes, junctional mucosa
-Negative for intestinal dysplasia on Alcian blue/PAS stain
-Negative for dysplasia
E. gastroesophageal junction, 1.5 cm above SCJ, biopsy
-Reflux changes; squamous mucosa
-Negative for fungal organisms on Alcian blue/PAS stain
GROSS DESCRIPTION:
A. The specimen is received in formalin and is labeled with the patient's name, DOB, and "biopsy proximal transverse scar". It contains two tan-brown irregular tissue fragments measuring 0.4-0.5 cm in greatest dimension which are submitted in toto in cassette A1.
B. The specimen is received in formalin and is labeled with the patient's name, DOB, and "biopsy duodenitis". It contains three tan-brown irregular tissue fragments measuring 0.3-0.5 cm in greatest dimension which are submitted in toto in cassette B1
C. The specimen is received in formalin and is labeled with the patient's name, DOB, and "biopsy 0.5 cm below SCJ". It contains four tan-brown irregular tissue fragments measuring 0.3-0.5 cm in greatest dimension which are submitted in toto in cassette C1.
D. The specimen is received in formalin and is labeled with the patient's name, DOB, and "biopsy 0.5 above SCJ". It contains five tan-brown irregular tissue fragments measuring 0.2-0.5 cm in greatest dimension which are submitted in toto in cassette D1.
E. The specimen is received in formalin and is labeled with the patient's name, DOB, and "biopsy 1.5 cm above SCJ". It contains three tan-brown irregular tissue fragments measuring 0.3-0.6 cm in greatest dimension which are submitted in toto in cassette E1.
Doctor's File Notes
History
Lab Test Results
Medication
Symptoms
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