OUT-PATIENT PATHOLOGY

MR No ............. : DC-39-09
Patient ............ : Mrs. Fatima Saleem
Age/Gender .... : 68 Years,7 Months,9 Days / Femal
http://www.shifa.com.pk Ordered By ..... : Dr. Farzana Shafqat - 146
Ordered On ..... : 14-FEB-23 02:11 PM
HISTOPATHOLOGY Specimen No . : S-2023-003549
Pickup point : 00051
Large Biopsy Verified On........ 24-FEB-23
: 09:03 AM
Printed on: 24-February -2023 @ 10:15:36 by: shifa_sms

Specimen
1) Gastric biopsy
2) Gastric polyp
3) Cecum biopsy
Clinical Information

This is a Computer GENERATED Report. It DOES NOT require any SIGNATURE or STAMP.
- Heartburn and constipation.
- Upper GI report shows normal, upper, middle and lower esophagus.
- Stomach shows mild mucosal erythema and edema throughout the stomach.
- Multiple small 1.0-2.0 mm gastric polyp with normal overlying mucosa likely fundic gland polyps.
- Duodenum shows mild mucosal erythema in duodenal bulb.
- Lower GI report shows no mass, hemorrhoids or bleeding. Mild mucosal erythema and cecum. Mild mucosal
erythema in cecum.
- Rest of visualized colonic mucosa was normal.
Diagnosis

1) GASTRIC BIOPSY:
- MILD CHRONIC MILD ACTIVE GASTRITIS.
- H.PYLORI MICRO-ORGANISM: NOT SEEN.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR MALIGNANCY.

2) GASTRIC POLYP (AS SUBMITTED), BIOPSY:

- MILD CHRONIC GASTRITIS.
- H.PYLORI MICRO-ORGANISM: NOT SEEN.
- ONE FRAGMENT WITH FINDINGS SUGGESTIVE
OF HYPERPLASTIC POLYP.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR MALIGNANCY.

3) CECUM, BIOPSY:
- LARGE BOWEL MUCOSAL FRAGMENTS SHOWING
MILD FOCAL ACTIVE INFLAMMATION.
- NO SIGNIFICANT CHRONIC COLITIS.
- NEGATIVE FOR GRANULOMATOUS INFLAMMATION.
- NEGATIVE FOR MALIGNANCY.
- SEE COMMENT.
Comments
Pigment-laden macrophages in lamina propria likely represent Melanosis coli. Correlation with history of
laxative use and colonoscopy findings is suggested.
Gross Examination
The specimen is received in formalin, in three containers labeled with patient's name and surgical number.

First part of the specimen is labeled as "GASTRIC". It consists of four pale yellow tissue fragments, collectively
measuring 0.7 x 0.4 x 0.2 cm. Entirely submitted in single cassette (1).
Fazal Ilahi Md Imran Ahmad M, FCAP Dr.Nadira Mamoon Dr.Humaira Nasir Dr.Ayesha Junaid Dr.Ghazanfar Abbas Dr.Tahir Aziz Ahmed
Senior Advisor Pathology Chief Pathologist/Director Associate Chief Consultant Consultant Haematologist Consultant Chemical Consultant Immunologist
D.Path Eng.D.C.P.London Lab Pathologist Histopathologist Professor of Pathology Pathologist Professor of Pathology
DABP FCAP FASC Assistant Professor of Consultant Histopathologist Professor of Pathology MBBS,MCPS,FCPS Assistant Professor of MBBS, MCPS,FCPS,FRC
Pathology Professor of Pathology MBBS,FCPS,MCPS,FRC Ext.3820 Pathology Path(UK)
MBBS, DABP (AP&Heme) MBBS,FCPS,FRC Path(UK) Path(UK) MBBS, FCPS. Ext:4348

Dr.Asna Haroon Khan Dr.Muhammad Usman Dr.Zafar Ali Dr.Zujajah Hameed Dr.Shawana Shahid Dr.Muhammad Bilal Dr.Sania Raza
Consultant Consultant Microbiologist Consultant Consultant Consultant Hematologist Associate Consultant Associate Consultant
Histopathologist MBBS,FCPS Histopathologist Histopathologist MBBS, FCPS Histopathology Microbiologist
MBBS,FCPS Ext:4283 Assistant Professor of MBBS, FCPS Assistant Professor of MBBS, FCPS Assistant Professor of
Ext: 4203 Pathology Ext: 4116 Pathology Ext: 4794 Pathology
MBBS, FCPS Ext: 4326 MBBS, FCPS

:
 OUT-PATIENT PATHOLOGY
MR No ............. : DC-39-09
Patient ............ : Mrs. Fatima Saleem
Age/Gender .... : 68 Years,7 Months,9 Days / Femal
http://www.shifa.com.pk Ordered By ..... : Dr. Farzana Shafqat - 146
Ordered On ..... : 14-FEB-23 02:11 PM
HISTOPATHOLOGY Specimen No . : S-2023-003549
Pickup point : 00051
Verified On........ 24-FEB-23
: 09:03 AM

Second part of the specimen is labeled as "GASTRIC POLYP". It consists of four tan brown tissue fragments,
collectively measuring 0.6 x 0.4 x 0.2 cm. Entirely submitted in single cassette (2).

Third part of the specimen is labeled as "CECUM". It consists of three tan brown tissue fragments, collectively
measuring 0.4 x 0.3 x 0.2 cm. Entirely submitted in single cassette (3). (Dictated by Dr. Nadia/ Dr. Amina/
Consultant Dr. Zubaria Mukhtar/ Transcriber Ehtasham)

This is a Computer GENERATED Report. It DOES NOT require any SIGNATURE or STAMP.
Microscopic Description
1) - TYPE OF BIOPSY: Endoscopic biopsy.
HISTOPATHOLOGICAL FINDINGS:
Sections show gastric biopsy with following changes:
- NUMBER OF BIOPSY FRAGMENTS: 04.
- H.PYLORI INFILTRATION: Not identified(immunostain examined).
- CHRONIC INFLAMMATION: Mild.
- INTESTINAL METAPLASIA: Not seen.
- ACTIVITY: Mild.
- ATROPHY: Not seen.
- DYSPLASIA: Not seen.
- OTHERS: Smooth muscle hyperplasia.

2) The sections show fragments of gastric mucosa with one fragment at level 1 showing few dilated glands.
There is mild chronic inflammation and foci of smooth muscle hyperplasia. No H.Pylori microorgansisms or
evidence of malignancy is identified in the sections examined.

3) - TYPE OF BIOPSY: Colonoscopic biopsy.

- HISTOPATHOLOGICAL FINDINGS:
- SITE OF BIOPSY: Cecum.
- EROSION: Absent.
- ULCERATION: Absent.
- DISTRIBUTION OF CHRONIC INFLAMMATION: focal.
- CRYPT ARCHITECTURAL DISTORTION: Not seen.
- MUCIN CONTENT: Intact.
- METAPLASIA: Absent.
- CRYPTITIS: Mild.
- CRYPT ABSCESS: Absent.
- GRANULOMAS: Not seen.
- DYSPLASIA: Not seen.
- BASEMENT MEMBRANES: Unremarkable.
- MUSCULARIS MUCOSA: Unremarkable.
- ADDITIONAL FINDINGS: Deposition of melanized ceroid in macrophages of lamina propria.

Verification
Muhammad Bilal
Associate Consultant Histopathology
MBBS, FCPS (Histopathology)
Ext: 4794

Fazal Ilahi Md Imran Ahmad M, FCAP
Senior Advisor Pathology Chief Pathologist/Director
D.Path Eng.D.C.P.London Lab
DABP FCAP FASC Assistant Professor of
Pathology
MBBS, DABP (AP&Heme)
Dr.Nadira Mamoon
Associate Chief
Pathologist
Consultant Histopathologist
Professor of Pathology
MBBS,FCPS,FRC Path(UK)
Dr.Humaira Nasir Dr.Ayesha Junaid Dr.Ghazanfar Abbas Dr.Tahir Aziz Ahmed
Consultant Consultant Haematologist Consultant Chemical Consultant Immunologist
Histopathologist Professor of Pathology Pathologist Professor of Pathology
Professor of Pathology MBBS,MCPS,FCPS Assistant Professor of MBBS, MCPS,FCPS,FRC
MBBS,FCPS,MCPS,FRC Ext.3820 Pathology Path(UK)
Path(UK) MBBS, FCPS. Ext:4348

Dr.Asna Haroon Khan Dr.Muhammad Usman Dr.Zafar Ali Dr.Zujajah Hameed Dr.Shawana Shahid Dr.Muhammad Bilal Dr.Sania Raza
Consultant Consultant Microbiologist Consultant Consultant Consultant Hematologist Associate Consultant Associate Consultant
Histopathologist MBBS,FCPS Histopathologist Histopathologist MBBS, FCPS Histopathology Microbiologist
MBBS,FCPS Ext:4283 Assistant Professor of MBBS, FCPS Assistant Professor of MBBS, FCPS Assistant Professor of
Ext: 4203 Pathology Ext: 4116 Pathology Ext: 4794 Pathology
MBBS, FCPS Ext: 4326 MBBS, FCPS