# Need Help Interpreting Biopsy Results from Colonoscopy



## jac521

I'm new to the forum and had a colonoscopy a couple of weeks ago.  I have a copy of the pathology report and was wondering if someone could help me interpret them.

"Clinical Information:  
1.  Rule out Celiac disease.
2.  Rule out Microsopic colitis.

Final Diagnosis:

1.  Duodenum, Biopsy:  Duodenal mucosa with mild chronic duodenitis; well preserved villous architecture.

2.  Duodenum Bulb, Biopsy:  Mild acute and chronic duodenitis.  Minimal Architectural changes.

3.  Colon, Right, Biopsy:  Colon mucosa with mildly increased lymphocytic inflitrates.  No definite evidence of colitis.

4.  Colon, Left, Biopsy:  Colon mucosa with mildly increased lymphocytic infiltrates.  No definite evidence of colitis."

Thanks for your help.
jac521


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## Trysha

Hello jac521
Your report really requires the interpretation be made by your GI specialist.
It represents part of the whole picture and needs your GI to put the picture together with other physical assessments made by him/her,
Duodenitis can precede ulcer formation and your doctor may want to treat this.
Interpretation of the colon biopsies also needs expert interpretation but could be suggestive of some kind of infection, again you need your GI to interpret this.
When is your next GI appointment?
Perhaps you could print out your questions to ask at that time.
Feel better soon
Hugs and best wishes
Trysha


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## Jennifer

Looks like you had an endoscopy and a colonoscopy done. The Duodenum it the first part of the small intestine that connects to the stomach. 

1. Duodenitis means inflammation of the Duodenum. Chronic means it ongoing. So that's mild, ongoing inflammation in the duodenum. Villi are "Tiny, finger-like projections that enable the small intestine to absorb nutrients from food." http://medical-dictionary.thefreedictionary.com/villi So well preserved means that there is little damage if any.

2. The Duodenum Bulb is the portion of the duodenum that's closest to the stomach.  Acute meaning a "rapid onset and following a short but severe course." http://www.thefreedictionary.com/acute So its saying that the inflammation is ongoing, aggressive yet mild with some damage done in the duodenum bulb. 

3. Lymphocytic is referencing the lymphoid tissue of the colon. Infiltrates: Cells or body fluids that have passed into a tissue or body cavity. http://medical-dictionary.thefreedictionary.com/Infiltrates Meaning that the lymphoid tissue of the colon has had fluid (unknown what, could be fecal matter or in reference to inflammation) enter into it and that its mild. They don't feel that its a sign of colitis and don't believe its concrete evidence of diverticulitis (bulging sacs that when fecal matter enters they become inflamed) otherwise it would have said that you had it in the report. 

4. Is the same as 3 but on the left side of the colon.

It says that biopsies were taken in each area so you'll have to wait for those results to come in in order for you to possibly have a concrete diagnosis. Its possible that they could find Microscopic Colitis after looking at the biopsies. We have a subforum for Microscopic Colitis here if you would like to check it out. http://www.crohnsforum.com/forumdisplay.php?f=258 Thus far though, no diagnosis has been made and Microscopic Colitis and Celiac have yet to be ruled out as your doctor needs the biopsy results. 

Blood tests are also used to rule out Celiac: http://labtestsonline.org/understanding/analytes/celiac-disease/tab/test


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## jac521

I was on Entocort EC 9 mgs. at the time of my Colonoscopy and Endoscopy.  Could the Entocort alter the biopsy results?


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## David

How long have you been on Entocort and have you been on a gluten free diet?


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## jac521

David -

I have been on 9 mgs of Entocort for 8 months.  I have not been on a gluten free diet.


Thanks.
jac521


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## David

Were they not able to access your terminal ileum with the colonoscopy?

With your previous thread, I would still want them to explain the enterocutaneous fistula which does NOT occur with microscopic colitis.  

Here is what is typically seen in biopsy results of Microscopic Colitis.  I don't know how much your entocort would change that.  So they put you on the entocort without knowing what was going on?

Histopathology:

In general, lymphocytic colitis looks just like collagenous colitis without the subepithelial collagen table. The surface epithelial damage with increased intraepithelial lymphocytes is often more prominent/intense in lymphocytic colitis. Just as in CC, there is generally a superficial plasmacytosis without crypt distortion in LC. There may be fewer lamina propria eosinophils in LC than are seen in CC. The surface damage and lymphocytosis may be patchy while the lamina propria plasmacytosis tends to be diffuse. The pathologist must avoid evaluating the number of intraepithelial lymphocytes overlying a lymphoid follicle, as one should normally see numerous intraepithelial lymphocytes there. One should also recognize that normally there are more intraepithelial lymphocytes in the right colon as compared to the left colon. A few foci of cryptitis or a rare crypt abscess may be seen in LC, but more neutrophilic inflammation than this suggests another diagnosis. Recently it has been recognized that some cases of lymphocytic colitis have less surface damage and more intraepithelial lymphocytes in the deeper crypt epithelium. Another variation of LC has been described with collections of histiocytes and poorly formed granulomas underneath the surface epithelium.

Differential Diagnosis:
The differential diagnosis of lymphocytic colitis is somewhat narrower than collagenous colitis. The resolving phase of infectious colitis can mimic LC, as there can be surface damage and a modest increase in intraepithelial lymphocytes. Lymphocytic colitis-like changes have also been described in an outbreak of chronic diarrhea linked to the water supply of cruise ship. This so-called “colonic epithelial lymphocytosis” seemed to have less surface damage as compared to lymphocytic colitis. Reports have also been made of lymphocytic colitis-like histology in patients with constipation as well as in patients with endoscopic abnormalities. Hence, it is important for the pathologist to make sure the clinical history is consistent with LC before making this diagnosis. There are also reported cases of Crohn’s disease with patchy areas showing a lymphocytic colitis-like pattern. Collagenous colitis may be confused with lymphocytic cases when only rectal biopsies are obtained or when the subepithelial collagen table in collagenous colitis is patchy and fairly thin.


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## jac521

David -

The Dr. told me after the colonoscopy that the terminal ileum was normal and that is what it states on my discharge papers.  However, I have been on the 9 mgs of Entocort.  Which, I think would make a difference?

I had a colonoscopy done in 2005.  When I went back to the Dr. he told me that he couldn't treat me for what was found on the colonoscopy as I was allergic to sulfa.  So I just figured it wasn't anything serious and never questioned him (big mistake).  In 2007, I started having Uveitis, skin sores and sweating like crazy.  I went to another GI Dr. and he got the records from the prior Dr's. scope in 2005.  He said that the pathology report showed "crypts, abscesses and mild inflammation".  (I have a copy of this report).  He couldn't get over the fact that I had never been treated by the other Dr. who found these things.  He then did a Colonoscopy and told me he found "granulomas".  I was diagnosed with "mild Crohn's disease".  He put me on Entocort and I did great.  After, I was tapered off the Entocort for about 4 mos., I found a red spot on my belly, above my belly button, and I thought it was a pimple and was rubbing Neosporin on it, when my finger went through my stomach.  (I didn't know anything about Fistulas at the time).  I went to an ER which was overflowing and they did a CAT scan, gave me an antibiotic and sent me home.  They never told me what it was.  I called my GI as soon as his office opened and told him what happened.  He said "we are going to do this over the phone, you don't need to come to the office".  He put me back on Entocort and prescribed Flagyl and Cipro.  I still didn't know what was wrong with me.  I then went to an Urgent care facility and the Dr. took a culture of the stuff in the hole in my stomach and it came back as being feces. It took approx. 3-4 mos. of being on the antibiotics for the fistula to heal.  The Dr. insisted that the Crohn's was worse than he originally though and wanted me to take 6-MP and I refused.


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## David

If the Entocort works well for you, yes, I think that would make a difference.

He likely wants to get a visual of where that stricturing is.  I'd jump through the hoops and go along with it.

Have they done a fecal calprotectin test on you out of curiosity?


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## jac521

I had an endoscope done at the same time as the colonoscopy.  After the scope the Dr. Told me that I had a small nodule in my stomach, that he thinks it is nothing and that he biopsied it.

The pathology report reads:

"Gastric Nodule, Biopsy:
Consistent with Hyperplastic Polyp.
No evidence of malignancy"

I called the Drs. office today and told them I wanted my results and they said they would tell the Dr.

A few hours later, I received a phone call from a Dr's. office I never heard of.  They told me that my Dr. referred me for an Endoscopic Ultrasound of the lump in my stomach and they wanted to do it this Friday.  I was dumbfounded.  I told them I know nothing of this, nothing was said to me about being referred to another Dr. or about another test.  I would think the Dr. I was being referred to would want to see me and examine me before he did an invasive test??  I kept questioning as to why I was being referred and they told me to talk to my Dr.  I never heard of an Endoscopic Ultrasound before.  I am totally in the dark as to why this is being ordered.  Do they need money, am I just a ginea pig, or what??  I just had an endoscopy and now they want to do another one and no one has told me anything as to what for, or why.  

Please help - I am overwhelmed, frustrated and confused!!!!!

Thanks.
Jo


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## David

Jo, I'd recommend starting a new thread for that one.  See if anyone else has had such a test or knows anything about it.  I don't, sorry.


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## jac521

David,

Thanks.  I will start a new thread tomorrow.

As for the Fecal test you mentioned, I never had that kind of test done.

Also, I have a pathology report from 2005 that said I had crypts, abscesses, and mild inflammation.  Aren't crypts only seen in Crohns??

Thanks. Jo


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## David

Hi Jo.  Crypt architecture should be normal in all causes of inflammation with the exception of Inflammatory Bowel Disease.  It can cause crypt architectural distortion.  It is a really significant finding.  Is your current GI aware of that biopsy report?

I'd discuss the idea of having your fecal calprotectin level tested with your doctor.


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## jac521

David,

The colonoscopy that showed the crypts was before I was ever put on any medication for CD.  It was done in 2005.  

Can you tell me why they haven't shown up on colonoscopies since?  Is it because I was on Entocort, or some other reason?

I am trying to find my copy of the biopsy report that showed crypts as I am not sure if the Dr. has it.

Thanks.
Jac521


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## David

I don't know the answer to that, sorry


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## jac521

David,

Also my 2007 colonoscopy showed granulomas.  Again, I had not been on meds.  I was not put on meds until after this colonoscopy.

Your thoughts are appreciated.

Thanks
Jo


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## David

Is your new GI aware of the granulomas?  That could give them more information to go on.  While Crohn's can have granulomas, there's other disorders that do as well.  Here's some reading for you.


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## jac521

The Dr. was supposed to get all my previous records wether he did or not I do not know.  I guess you can't assume anything.

After my scope he told me I didn't have Crohns disease.  I asked him why when I am off of Entocort for 4 or 5 months do I get sick and have to go back on it.  He told me it could be my Adrenal glands.  My Crohns was found in my small bowel in 2007.  He has me utterly confused and I am thinking of changing Drs.  His bedside manner stinks too.

I went to him because of pain in my left side and now the pain is worse and I am having diffiiculty passing stools.  He told me I call the office too much.  I am in pain who am I supposed to call Ghostbusters.  Might as well for all the good he does.


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## jac521

David - 

I found the biopsy results from 2005.

"Random Colon Biopsy - Mildly active Inflammatory Bowel Disease, type Indeterminate."

"Comment:  This specimen consists of multiple fragraments of colonic mucosa, some of which show ACUTE CRYPTITIS and CRYPT ABSCESS FORMATION, CHRONIC INFLAMMATON, AND SCATTERED EOSIONOPHILS  AND COULD REPRESENT AN ACUTE SELF LIMITED COLITIS."

Your input is appreciated.

Thanks.
Jo


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## Patricia56

Never assume that the doctor got your previous records or that he/she has actually reviewed those records.

I cannot say whether your current gi's reversal of your previous diagnosis is right or wrong but you need to make sure he has all the information.

The places you had the previous scopes done - if you have copies of the written pathology reports I would put them together along with a list of the doctor's who were treating you at that time. Contact information for each one is very important so be sure to include it.

I would hand carry it to your new GI's office and tell the front desk that you want them to make copies for the GI and that you want to do releases so that he can get information from these other places.

Do not leave your originals there. Stand there and wait while they make the copies. If his NP or nurse is available while you're there then I would speak with her and make sure she/he gets those copies.

If you have any photographs from the scopes that show inflammation, etc. then I would take them along too so they can see them and make photocopies.

As for the adrenal theory, if he thinks that so then he should be sending you to an endocrinologist for a work up because if he's right then you need to be appropriately treated for it and I can pretty much guarantee you that Entocort is not going to the be treatment the Endocrinologist gives you. And adrenal insufficiency/failure (what the GI is implyinig you have) can be fatal so that issue needs to be addressed right away.

Sounds like you are getting a bit of a run around but if the GI doesn't have the previous docs then that may help explain the problems.


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## jac521

Approx. 3 years ago I had my adrenals checked by an endocrinologist.

I don't like my current Dr.  He has a big ego, he's rude and his bed side manner stinks.  He thinks because he is a Crohns specialist that no other Drs. reports, findings, etc. are right because they are not his.  

I thought I could over look his bad manners if he was a good Dr.  However, in my opinion he has bad manners and is not a good Dr.  He just keeps wanting to do expensive tests on me it seems and the tests aren't addressing the problem of the pain in my left side.

Thanks.
Jac521


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## David

jac521 said:


> David -
> 
> I found the biopsy results from 2005.
> 
> "Random Colon Biopsy - Mildly active Inflammatory Bowel Disease, type Indeterminate."
> 
> "Comment:  This specimen consists of multiple fragraments of colonic mucosa, some of which show ACUTE CRYPTITIS and CRYPT ABSCESS FORMATION, CHRONIC INFLAMMATON, AND SCATTERED EOSIONOPHILS  AND COULD REPRESENT AN ACUTE SELF LIMITED COLITIS."
> 
> Your input is appreciated.
> 
> Thanks.
> Jo


Aussie - If you're out there, any thoughts on these biopsy results?


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## Aussie

Hi David and Jac, in regards to the 2005 biopsy, the finding of chronic inflammation would usually mean IBD (although the pathologist really should've mentioned what the crypt architecture was like...). The cryptitis and crypt abscesses are seen in any acute colitis. Would ignore scattered eosinophils.

When you add that to your extraintestinal manifestations (uveitis) and then for good measure throw in you enterocutaneous fistula and previous colonoscopy with granulomas.... You have ileocolonic Crohn's disease (unless the fistula came from the colon).

This makes me wonder why you current doctor would be questioning microscopic colitis or coeliac disease on your most recent scopes, whose findings are quite non-specific.  Entocort is good for bringing small bowel crohn's into remission, tends not to work as well in the colon (although some peoples colon's don't read the textbooks...), rubbish for maintaining remission.

Also, IBD is not a static disease and the clinical / endoscopic / histologic features can all change with time and treatment - the histologic features can return to normal. You will particularly see the acute inflammation (cryptis, crypt abscesses) settle with medications to induce remission (ie. steroids).

The fact that you have fistulising Crohn's, then your are in a poorer prognostic group. I would suggest.

1. Quantify inflammation with a faecal calprotectin.
2. MR enterography to examine the small bowel.
3. Start maintenance medication, either thiopurine (6MP or AZA) or biologic therapy.
4. Stop smoking (if you smoke).

Best wishes.


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## jac521

HI AUSSIE - AND THANKS SO MUCH!!!!

I have been on and off of Entocort since 2008.  I currently have been taking 9 mgs. for 7months.  Everytime I try to do a taper, I get symptoms.  Can the Entocort stop working or can you build up a tolerance for it?  I changed Drs. this week and my new Dr. is talking Biologics which I do not want to take.

I had an MRE of small bowel a few months ago.  It showed strictures and no active inflammation.  However, I question the MRE's validity as it says I have a "normal gallbladder and uterus" and both have been removed.

Your thoughts are appreciated.


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## Aussie

Hi Jac, the MRE is a dedicated scan of the bowel, not really that good for other organs. Also, it's not that good at differentiating inflammatory vs scar tissue strictures. In regards to any ongoing inflammation, a faecal calprotectin would be the most accurate. 

You don't really develop tolerance to steroids, but they tend to stop working after around 6 months (in trials).

Entocort is a drug to get you into remission, NOT keep you in remission. Crohn's is a disease that can damage your bowel, sometimes when you have symptoms or not. Repeated courses of steroids with no maintenance therapy is not good practice to avoid further bowel damage.

Good luck.


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## David

Hi Aussie.  Thank you so much!  Jac's "enterocutaneous fistula" is being questioned as being a fistula by their new doctor and as such, they're also questioning whether it is Crohn's or not.  The fistula presented as a hole with discharge that an urgent care, "Cultured as feces" according to jac521.  After being prescribed Cipro, Flagyl and Entocort, it closed within three months and a fistulogram was not done.  As you state, "You have ileocolonic Crohn's disease (unless the fistula came from the colon)" I thought I'd get your opinion as to what, if anything this might change.  They were tested for all STD's that may cause a fistula.

Thank you!


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## jac521

Hi Aussie -  The Entercutaneous fistula that David is referring to was about an inch straight above my belly button.  

Thanks.
Jac


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## Aussie

Hi David and Jac, if you have a hole in your belly with faeces coming from it, it's an enterocutaneous fistula. When you add that to the other findings, this is a pretty slam dunk diagnosis for Crohn's disease - the main impact the fistula would have is that it would put you in a poorer prognostic group and you really should be on regular medication, not steroids. 

If you get symptoms when you wean the steroids, then a steroid-sparing agent to maintain remission should be started, then you should be weaned off the steroids.

Best wishes.


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