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3030 South Gessner Rd, Ste 270 Houston Tx, 77063

Ph: 832.962.8788 Fax: 832.962.8788


Medical Director: Emma Diaz de Leon, M.D.

Patient Information
Patient:
Sex:
DOB:
Age:
MRN:
PCP:

Dawoud, Nessren M
Female
04/17/1960
55
146271
Nema Uwaydah, M.D.

Referring Physician
Name: Radwan Al-Sabbagh, M.D.
Address: 3030 South Gessner Dr. 150
Houston, TX 77063
Phone: (713) 587-0909

Specimen Information
Result ID:
Accession:
Collected:
Received:
Reported:

GA15-0786
UP15-504046
08/27/2015
08/28/2015 14:18
09/01/2015 13:03

Facility: Physicians Endoscopy Center

Surgical Pathology Report


Clinical History
787.29 OTHER DYSPHAGIA, 530.81 ESOPHAGEAL REFLUX, 553.3 DIAPHRAGMATIC HERNIA WITHOUT
OBSTRUCTION OR GANGRENE, 562.10 DIVERTICULOSIS OF COLON (WITHOUT HEMORRHAGE), 211.3 BENIGN
NEOPLASM OF COLON

Diagnosis
Stomach, antrum and body, biopsy:
- FRAGMENTS OF FUNDIC/BODY TYPE GASTRIC MUCOSA WITH MINIMAL CHRONIC INACTIVE GASTRITIS
- NO HELICOBACTER PYLORI-LIKE ORGANISMS, INTESTINAL METAPLASIA, DYSPLASIA OR MALIGNANCY
IDENTIFIED
GE junction, biopsy:
- FRAGMENTS OF SQUAMOUS EPITHELIUM WITH MILD CHRONIC INFLAMMATION
- NO GLANDULAR/COLUMNAR EPITHELIUM, DYSPLASIA OR MALIGNANCY IDENTIFIED
Colon, descending, polypectomy:
- FRAGMENTS OF COLONIC MUCOSA WITH LYMPHOID AGGREGATE AND CHANGES SUGGESTIVE OF
HYPERPLASTIC POLYP
- NO HIGH-GRADE DYSPLASIA OR MALIGNANCY IDENTIFIED
Colon, sigmoid, polypectomy:
- FRAGMENTS OF COLONIC MUCOSA WITH LYMPHOID AGGREGATES
- NO DYSPLASIA OR MALIGNANCY IDENTIFIED

Images

Descending colon polyp

Lymphoid aggregate

Gross Description
A.
B.
C.
D.

"Antrum and body biopsy" Received in formalin are two tan tissue fragments, 0.4 and 0.5 cm, all as A.
"GE junction biopsy" Received in formalin is a tan tissue fragment, 0.4 cm, all as B.
"Descending colon polyp" Received in formalin are two tan tissue fragments, 0.7 and 0.9 cm, all as C.
"Sigmoid colon polyp" Received in formalin are two tan tissue fragments, 0.7 and 0.7 cm, all as D. /jw

Microscopic Findings
A. "Antrum and body biopsy" The biopsy consists of fundic/body type mucosa with minimal chronic inflammation. No acute activity,
Helicobacter pylori-like organisms (H. pylori immunostain), intestinal metaplasia (Alcian Blue/PAS), dysplasia or malignancy
identified.
B. "GE junction biopsy" The biopsy shows fragments of squamous epithelium with mild chronic inflammation. Noelongation of
papillae, increase in eosinophils, glandular/columnar epithelium, fungal organisms (AB/PAS), dysplasia or malignancy is
identified.
C. "Descending colon polyp" The biopsy shows fragments of colonic mucosa with focal hyperplastic change and lymphoid
aggregate. Additional deeper levels were examined.
D. "Sigmoid colon polyp" The biopsy shows fragments of colonic mucosa with intact architecture and lymphoid aggregates.

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3030 South Gessner Rd, Ste 270 Houston Tx, 77063


Ph: 832.962.8788 Fax: 832.962.8788
Medical Director: Emma Diaz de Leon, M.D.

Patient Information
Patient: Dawoud, Nessren M

Referring Physician
Name: Radwan Al-Sabbagh, M.D.

Specimen Information
Result ID:

GA15-0786

Additional deeper levels were examined.

ELECTRONIC SIGNATURE
Lizmarie Andino, M.D.
Screening Location:

CPT CODE(S)
88305 x4, 88313 x2, 88342

ICD-9 CODE(S)
535.5

1140 Business Center Dr. Suite 370, Houston, TX 77043

Site(s) indicated on the organ map and/or images are based upon clinical information provided and do not necessarily show the precise location of the specimen. The graphical
representations contained in this report, if any, are not intended to replace a total reading of this report.
Specimens Processed by Gastroenterology & Liver Associates PLLC. CLIA # 45D2020900, 3030 South Gessner Road, #290 Houston, TX 77063 Ph: 713.783.4252

*** END OF REPORT ***

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