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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
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
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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Patient Information
Patient: Dawoud, Nessren M
Referring Physician
Name: Radwan Al-Sabbagh, M.D.
Specimen Information
Result ID:
GA15-0786
ELECTRONIC SIGNATURE
Lizmarie Andino, M.D.
Screening Location:
CPT CODE(S)
88305 x4, 88313 x2, 88342
ICD-9 CODE(S)
535.5
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
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