Surgical Pathology
Patient Case Number: SXP01-Williams, Carrie
Patient Name: Carrie Williams | DOB: 02-10-75 | Sex: F
Submitting Physician Brandon Smith, MD | Attending Physician Nancy Smalls, MD
Collected Date/Time 09-07-XX 11:20AM | Received Date/Time 09-07-XX 11:30AM
Accession Number: HL-11-34574
Clinical Summary/Clinical Impression: GI bleed, r/o sprue, H. pylori

# Gross Description:

# Part A-Received labeled small bowel in formalin are fragments of tissue collectively measuring about 1 cm in greatest dimension processed entirely. One block.

# Part B-Received labeled gastric in formalin are fragments of tissue collecting measuring about 0.8 cm in greatest dimension processed entirely. One block.

# Microscopic Description:

# Part A-Duodenal mucosa shows an intact villous architecture without increased intraepithelial lymphocytes. No Brunner gland hyperplasia, fovelolar metaplasia, active inflammation or Giardia are identified.

# Part B-Gastric mucosa shows mildly reactive appearing foveolar epithelium and underlying gastric glands with lamina propria showing fibromuscular tissue with scattered chronic inflammatory cells. No intestinal metaplasia is identified.

Warthin-Starry stain reveals no Helicobacter pylori forms.

# Pathologic Diagnosis:

# Part A-Small bowel, duodenum biopsy No diagnostic abnormality

# Part B-Stomach, biopsy

Mild chronic gastritis

# Electronically Signed by: Peter Deutch, MD

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