Reporting format for Colonic biopsies-IBD

Microscopy:

Chronicity: 

  • Mucosal architecture(Diffuse-UC; Patchy changes-CD): 
    • Glands-Normal / distorted glands
    • Crypt density-Normal/decreased (>1 crypt separation b/w adjacent crypts)
    • Crypt atrophy-Present/absent (distance b/w crypt base and muscularis mucosa increased)
    • Surface irregularity-present/absent
    • Villous architecture
  • Lamina propria cellularity: 
    • Diffuse(UC)/Patchy(CD/quiescent or longstanding UC); Mild/mod/severe; Transmucosal(UC)/Transmural(CD)
    • Basal plasmacytosis(UC+, infectious colitis-,CD-)
  • Epithelial abnormality:
    • Mucin depletion: Reduction in number of goblet cells/ reduced intracellular mucin.
  • Others
    • Granulomas(Not associated with crypt destruction and extravasated mucin-UC): Present (CD-classical finding, TB, parasites, cryptolytic granuloma in UC) / absent(UC)
    • Paneth cell metaplasia
    • Hypertrophy of MM
    • Submucosal fibrosis

Activity: 

  • Epithelial abnormality:
    • Erosion, ulceration, flattening, focal cell loss
  • Crypt abnormality:
    • Cryptitis
    • Crypt abscess
  • Lamina propria 
    • Increased neutrophilic infiltrate

Note: In biopsies sent from known cases of IBD in quiescent stage: Increased lamina propria eosinophils, basal plasmacytosis and mildly active disease is suggestive of ensuing relapse.

Dysplasia: Negative for dysplasia (Regenerating epithelium)/ Indefinite for dysplasia/ Positive for Low grade dysplasia or High grade dysplasia

Impression: 

Chronic Colitis with/without Activity, likely UC/CD/IBDU

Negative/Positive for high/low grade dysplasia

Or 

Known case of UC/CD in remission/quiescent stage(Architectural abnormality+/-, Activity-, Basal plasmacytosis-, Eosinophils+/-)/ quiescent stage with features of   ensuing relapse(Architectural abnormality+/-, Mild Activity+, Basal plasmacytosis+, Eosinophils++)

Negative/Positive for high/low grade dysplasia