This document discusses endoscopic intestinal biopsy techniques and interpretation. It describes how biopsies can be used to directly visualize and obtain samples from the gastrointestinal tract. Indications for biopsies of the small intestine and colon are provided. Proper biopsy handling, processing, and interpretation are discussed, including patterns of abnormal mucosa. Specific entities associated with villous abnormalities and diagnostic features in biopsies of the small intestine and colon are outlined. Factors to consider when delivering a diagnosis of colitis are also presented.

1. Interpretation of Endoscopic
Intestinal Biopsy
Dr.Mrs.Vaidya

2. Use of Fiberoptic Endoscope
 Direct visualization of GIT
 Taking photographs
 Cytological specimens
 Taking biopsies
 Undertaking therapeutic procedures

3. Indications for biopsies :
 Small intestine :
1.To know the nature of duodenal ulcer
2. To detect peri-ampullary carcinoma
3. To look for parasites [giardia ,
strongyloides ]
4. Malabsorption study
5. Lymphoproliferative disorders –IPSID &
lymphomas

4. Indication for biopsies :
 Colo –rectal :
1. Differetiate bet different types of colities
2. Diagnose IBD –UC ,Crohn”s disease , etc.
3. Monitor pt of UC & detect dysplasia or
malignant change
4. Detect the nature polyp & identify early
malignant change
5. To differentiate Ca from Solitary rectal ulcer
6. Detect amyloidosis

5. Contraindication for biopsies :
 Never performed in uncooperative pt
 Without informed consent
 H/o bleeding disorders
 H/o acute perforation

6. Endoscopic biopsy forceps :
Forceps Diamete
r of jaw
[mm]
Tissue
wt
ave[mg]
Muscula
ris
mucosa
adequsy
smallest 1.8 3.3 1/3 of bx inadequ
ate
Std.bx.
Forcep
2.4 5.9 2/3 of bx adequat
e
Jumbo 3.4 15.5 All bx BEST

7. Endoscopic bx forceps :
2 cup shaped jaws – round / elliptical
,serrated / non serrated
Best to use a forcep with central spike to
fix the instrument on mucosa
Other techniques for full thickness bx
specimen –FNAB thr endoscope ,snare
bx technique-electrocoagulation

8. Gastrointestinal Bx processing
for Light microscopy :
 Essential pre-requisite for HP evaluation
 Careful handling
 Proper orientation –1. Magnifying lens
2. Orienting mucosal surface upward –by mounting bx on Filter
paper/ wire mesh/ plastic mesh/ frosted glass/ vegetable
matrix[ cucumber slice]/ gelfoam,etc.even casette top
 Fixation –10% buffered formalin for 2-3 hr .bouin’s fluid or
halland’s sol.
 Automatic tissue processor or by hand processing in short
cycles
 Ascending grades of alcohol -30 mins each
 Xylol*3 -30 mins each
 Paraffin bath *2 -60 min each
 Orientation is imp while making the paraffin block
 Step sections at 3-4 level

9. Interpretation of Biopsies :
 It requires good communication bet
endoscopist & pathologist .
 REAL CHALLEHGE : as Bx is very
SMALL
 Pathologist must know :clinical history,
physical findings, result of radiographic & lab studies ,
ind. For scopy, endoscopic findings & site of Bx,etc

So complete scopy report with Bx is necessory.

10. Interpretation of Jejunal Bx :
 Imp step in
evaluating pt with
MALABSORPTION.
 Normal villous/crypt
ratio -3:1 or 5:1
 Intraepithelial
lymphocytes- 1-5
enterocytes

11. Dissecting microscopy imp in
interpreting jejunal bx in
malabsorption
 Grade 1 :villi finger or leaf like
 Grade 2 :leaflike with fusion to form
small ridges or convolutions
 Grade 3 :lost with flattening of mucosa
 grade 1 & 2 villi –normal individuals in
India


12. Patterns of Abnormal SI
Mucosa :
 Severe villous abnormality :flat mucosa , no
villi :villous atrophy
 Variable villous abnormality : villi focally flat or
mild to mod villous shortening
 Crypt hyperplasia or hypoplasia
 Increased intraepithelial lymphocytes : non
specific or with features that suggest sp
diagnosis ie. Numerous eosinophils,
granulomas, parasites .

13. Enteties ass. With :
 Diffuse severe villous
abn. & crypt hyperplasia
1.Celiac sprue
2.Refractory/ unclassified
sprue
3.other protein allergies
4.Lymphocytic
enterocolitis
 Variable villous abn. &
crypt hypoplasia
1.malnutrition-kwashiorkor
2. Radiation & chemo.
Effect
3.End stage refractory
sprue
4.microvillous inclusion
sprue

14. Celiac sprue :
 Villous/ crypt ratio :
 Normal – 2.5 or >
 Grade 1: 2 –2.5
 Grade 2: 1- 2
 Grade 3: 1- 0.5
 Grade 4: < 0.5
 Grade 3 & 4 –with
celiac disease

16. SI bx
 Non specific variable villus abn. , usually not
flat
1. Changes ass. With DH
2. Tropical sprue
3. Infections
4. Mastocytosis
5. Autoimmune enteropathy

18. SI bx
 Variable villus abn. With specific diagnostic
chahges :
1. Whipple disease
2. Mycobacterium avium intercellulare
complex inf.
3. Parasitic infestation [giardia ]
4. Abetalipoproteinemia
5. Eosinophilia gastroenteritis
6. Lymphagiectasia
7. Intestinal lymphoma

23. Abetalipoproteinemia
 Apical villous cytoplasm
shows vacuolation –due
bto inability to synthesis
B-lipoprotein
 acanthocytic
erythrocytes-due to lipid
membrane defect
 Failure to thrive,
diarrhea, steatorhea

24. Eosinophilic enteritis

25. Lymphagiectesia

26. Intestinal lymphoma
feature MALT[ IPSID]
{B cell lymph.}
EATCL [T cell
lymphoma ]
age 20 –30 50 –60
ass.
Conditions
Developing
countries
Celiac disease
site Jejunum &
duodenum
same

27. Intestinal lymphoma
Features MALT [IPSID ] EATCL [T
CELL
LYMPHOMA ]
Microscopy Immunoblastic,
polymorphous,sm
all
cleaved,plasmac
ytoid; R-S-like,
Lymphoepithelial
lesions;
Follicular
Polymorphic,
immunoblast &
R-S-like cell,
Occasionally
eosinophils

28. Colonic bx  Luminal surface is
straight
 Colonic tubules are
tightly packed,parallel &
nonbranching ,all
closely app. muscularis
mucosae
 Globlet cells numerous .
 Scattered intramucosal
lymphoid aggregates
 Overlying them
flattened surface
epithelial cells –M cells
 Paneth cells- base of

29. Differential diagnosis of IBD -
 ACUTE SEIF
LIMITED
ENTEROCOLITIS
shigella,c. jejuni
 UNUSUAL FORMS
Collagenous
Lymphocytic
Pseudomembranous
 CHRONIC IDIOPATHIC
COLITIS
Crohn’s disease [CD]
Ulcerative colitis [UC]
Resolving UC
 CHRONIC INF.
TB ,Yersinia ,Spirochete
CMV
Parasites

30. Why to bother to make DD -
 Majority of cases of diarrhea are self
limited or acute inf.-thus NOT to
mislable them as IBD ,CD or UC
 Surgical therapeutic procedure
interventions can differ in CD & UC

31. General features
Features Acute Colitis Chronic Colitis
General
architecture of
epithelium &
cyrpts
PRESERVATI
ON
ALTERATION
Lamina propria Mixed
inflammatory
cells –
polymorphs
Inc.cellullarity ,
lympho.,plasm
a
cells,poly.,bas
al lymphoid
follicles

32. Active colitis pattern :
features Ulcerative
colitis
Crohn’s
disease
Infectious
colitis
Architectural
abnormality
diffuse focal Usually focal
Irregular
luminal surface
diffuse
,undulating or
villous
may be focal Sometime focal
Mucin
depletion
&secretion
yes,diffuse
impaired
Usually focal
,sightly
impaired/
increased
Usually focal
Paneth cell
metaplasia
Common
feature of UC
- - Not seen

33. Active colitis pattern :
feature Ulcerative
colitis
Crohn’s
disease
Infectious
colitis
Crypt
abscesses &
cryptitis
yes focally ,yes Yes ,luminal
accentuation
Location of
inflam.
Mucosal,
submucosal
transmural mucosal
Basal
plasmacytosis
yes absent Usually absent
Granuloma no yes,28% no
Neutrophils in
lamina propria
no no usually yes

39. Granuloma :
 Sarcoid granuloma :diagnosis of crohn’s
 Non confluent , non caseating
 Best in submucosa ,rarely present in
endo.ileal bx[3%]
 also in Yersinia enteritis
 C D in absence of granulomas confident in
30-40%, based on patchy inflammation, crypt
& goblet changes & basal lymphoid agg.
 In T B :caseating granuloma
:acid fast bacilli [taken up by M cells ]

40. Villous surface, distorted crypt
architecture ,mixed LP cellularity :- 100%
predictive of IBD
FEATURE SENSITIVITY % PPV %
Villous mucosal
surface
26.4 100
Paneth cell
metaplasia
75.4 100
Distorted crypt
architecture
1.1 97.2
Basal lymphoid agg. 82.4 93.1
Increase in plasma
cells
86.6 85.2
Granuloma 8.8 66.7

41. Deliver a diagnosis of Acute-Chronic
colitis :
 Most reliable criteria not always present
 combination of feature hv to be used
 Don’t be afraid to mention your doubt
rather than to deliver a wrong diagnosis
 Remember that clinician often don’t
know & will hv to reevaluate the pt

42. Psedomembranous colitis :
 Small surface
erosion bet. crypts
covered with luminal
spray of pmn or
mucus
 Shows yellow
plaque on
colonoscopy

43. Collagenous colitis :
 Normal colonic
subepithelial
collagen layer : 5
microns
 Here, increase to 15
microns or more
 Colonoscopy &
barium enema:
normal

44. Lymphocytic colitis :