Histopathological spectrum of lesions in gastrointestinal endoscopic biopsy: A prospective study of 500 cases

Inclusion criteria

Exclusion criteria

These filter paper mounted biopsies were received in the properly labelled and tightly closed container containing 10% formalin. Which was then examined grossly for the number and appearance. After fixation biopsy was processed and embedded in paraffin with orienting the specimen mucosal surface uppermost. Three to four micron thick sections were cut perpendicular to this surface. Sections were stained with routine Hematoxylin and Eosin stain (H and E) and mounted with coverslips using Distyrene Plasticizer Xylene (DPX) as mountant. Additional sections were stained with Giemsa to observe H. Pylori and Periodic Acid Schiff (PAS) stain were performed wherever necessary. Analysis of the spectrum of the lesion as done. For celiac disease Modified Marsh classification4 was done on duodenal biopsies.5 All tumours were classified according to WHO classification.

Oesophagal biopsy

Maximum no of oesophageal biopsy cases was in their 7^th decades of life. Male: Female ratio was 1.89:1. Neoplastic lesions (76.5%) outnumbered the non-neoplastic conditions (23.5%) making a 3.26:1 ratio. Among the neoplastic lesions squamous cell carcinoma was the most prevalent lesion forming 98.41%. Poorly differentiated adenocarcinoma accounting for 1.58%. Majority of squamous cell carcinoma were moderately differentiated. The youngest patient with squamous cell carcinoma was a female of 28years. The most common age group involved was 6^th decades of life. Mean age of malignant oesophagal tumour was 52 years. The second most common lesion was esophagitis accounting for 11.11% cases. Three of eighty-one biopsies were sent with clinical suspicion of Barrett’s oesophagus on endoscopy. Microscopic examination showed gastric type mucosa with and without intestinal metaplasia. Dysplastic squamous cell lining was seen in 3 of the biopsies. (Table 2 A)(Figure 1 A, B, C)

Gastric biopsy

The most common endoscopic biopsy was gastric biopsy accounting for 183 out of 500 cases (36.6%) and the most common age group was 51 to 60 years, accounting for 24.04%. Male: female ratio was 1.54:1. The youngest patient was 9 years old male child shows histopathologic features of Helicobacter Pylori(H.Pylori) associated with chronic gastritis. Six of 183 cases (3.3%) were within normal histologic limits which included the 90 years old female patients also. Out of 183 gastric biopsies, 139(75.9%) cases were non- neoplastic and 38(20.7%) cases were neoplastic. Most common malignancy was moderately differentiated adenocarcinoma. Six out of 34 cases (17.64%) cases show histopathologic features of signet ring adenocarcinoma. Two cases showed a dense monomorphic population of lymphoid cells infiltrating the entire biopsy tissue. The native tissue was barely visible in the biopsy submitted for the examination. Diagnosed with lymphoma was offered. Among 139 cases of non-neoplastic lesion 136 shows histopathologic features of gastritis. On microscopic examination, 3.67% of cases show gastric mucosa infiltration by neutrophil resulting in the diagnosis of acute gastritis. Chronic gastritis was seen in 81.61% biopsies having plasma cell, lymphocytes infiltrating gastric mucosa. Nineteen cases (13.97%) showed features of chronic active gastritis. H. pylori infection was seen in 52.20% of cases. Which is confirmed by Giemsa stain as curvilinear bacteria. One case of atrophic gastritis was also seen. There were features of chronic gastritis along with glandular atrophy. (Table 2 B) (Figure 1D, Figure 2 A,B,C,D)

Duodenal biopsy

Among 119 cases of duodenum biopsies, all were non-neoplastic. Male: Female ratio was 0.72:1. Commonest age group involved was 4^th decades. The youngest patient was 11 years male and the oldest patient was 91 years female were having Chronic Non-Specific Duodenitis as majority of the cases (58.82%). The microscopic exam showed increased intraepithelial lymphocytes(IEL), plasma cell infiltrates and oedema in lamina propria. In 35cases (29.41%) duodenum biopsy was submitted with a clinical impression of malabsorption syndrome and to rule out celiac disease(CD). Anti-transglutaminase antibodies were done in only 12 of the patients. All were having either villous changes, scalloping of the duodenal mucosa on endoscopy or strong clinical suspicion. Rest 23 cases of suspected celiac disease were either serologically negative or Anti-Transglutaminase Antibodies level not done. Fifteen out of thirty-five cases showed only increased intraepithelial lymphocytes more than 30/100enterocytes with mild oedema in lamina propria falling in Modified Marsh grade 1 celiac disease. Seven cases showed increased IEL >30/100 enterocytes and mild to moderate crypt hyperplasia histopathologically graded as Modified Marsh grade 2 celiac disease. Additional villous atrophy was noted in 13 of the cases. Three with total villous atrophy (Modified Marsh grade 3c). Subtotal (grade 3b) and partial villous atrophy (grade 3a) were seen in four and six cases respectively. Among those with increase Anti-transglutaminase antibodies level three were of grade 3c, four and two of 3a and 3b respectively, two of grade 2 and one case of grade 1. Around 10% of biopsies showed normal histology of duodenum. Dysplasia and ulcer were observed in one case each.(Table 3 A) (Figure 3 A,B,C)

Colorectal biopsy

Among all the colonic biopsies, histologically 65 cases (55.55%) were diagnosed as non-neoplastic lesions and 43 cases (36.75%) were diagnosed as neoplastic lesions. The sixth decade was the commonest age group involved. Mean age being 50.72 years. The youngest patient was four years old male with a juvenile polyp. Microscopic examination showed cystically dilated glands filled with inspissated inflammatory debris in an edematous lamina propria. There was inflammatory cell infiltrate in lamina propria. The oldest patient was 95 years old male with an adenomatous polyp. Nine out of 117 cases (7.69%) were within normal histological limits. Among the non-neoplastic lesion colitis was the commonest lesion (24.78%) followed by inflammatory bowel disease(IBD) accounting for 17.09% of cases. Seventeen of 20 cases of IBD cases (85%) diagnosed as ulcerative colitis. There was evidence of cryptitis, crypt abscess, crypt distortion, basal plasmacytosis and mixed inflammatory cell infiltrate in lamina propria. Three of IBD cases showed non-caseating granulomas and transmural lymphoplasmacytic infiltrate and were signed out as Crohn's disease. Other non-neoplastic polyps four cases of the juvenile polyp, two Hyperplastic polyp characterized by elongated glands and crypts without serrated appearance. Six cases of inflammatory polyp having focal mucosal erosions and inflammatory cells infiltration in lamina propria seen.

Among 43 neoplastic lesions, benign lesions were in seen in 12 cases (27.90%) and Malignant lesions were observed in 36 cases (83. 72%). One case showed dysplasia of high-grade in the glandular lining. Amid the benign lesion, 8 cases of adenomatous polyp all showed histopathologic features of tubular adenoma characterized by an increased number of tubular glands with nuclear stratification, hyperchromatic nuclei limited to the lower one-third of glandular epithelium. High-grade dysplasia was observed in 4 cases of an adenomatous polyp.

Thirty six cases of adenocarcinomas, commonest being moderately differentiated, identified which was characterized by malignant glands with poor outlines. Well-differentiated adenocarcinomas were seen in 9 biopsies, characterized by well-formed malignant glands with infiltration into the submucosa. Poorly differentiated carcinomas were observed in 6 cases, characterized by malignant cells in sheet, cords and groups with no glandular structures. Signet shaped malignant cells infiltrating into the submucosa was observed in one case. Mean age of malignancy was 51.62 years. (Table 3 B) (Figure 3D, Figure 4A, B, C, D)

Figure 1

A: Barrett’s oesophagus(10x H and E); B: Well Differentiated Squamous Cell Carcinoma oesophagus(10x H and E); C: Poorly Differentiated Adenocarcinoma oesophagus(40x H and E); D: Atrophic Gastritis(4x H and E)

Figure 2

A: Chronic Active Gastritis(40x H and E); B: H.Pylori (100x Giemsa); C: Signet Ring Adenocarcinoma Stomach (40 x H and E); D: Lymphoma Stomach (10x H and E)

Figure 3

A: Modified Marsh Grade 3a Celiac; B: Modified Marsh Grade 3b Celiac; C: Modified Marsh Grade 3c Celiac; D: Juvenile Polyp Colon

Figure 4

A: Non Specific Colitis; B: Granuloma Colon; C: Crohn’s Colon; D: Adenomatous Polyp with Dysplasia

Figure 5

Adenocarcinoma colon

Oesophagal biopsy

The present study is comparable with Somani et al.6 and Jaynul Islam.7 et al. In all the three studies the most common age group involved was 7^th decades of life with a male predominance. In our study neoplastic lesions (77.7%) were more commonly encountered than non-neoplastic lesions (22. 3%). Squamous cell carcinoma was the most common among neoplastic lesion. Mean age of malignancy was 51.94years whereas Jaynul islam observed a mean age of 56.56 Years for the same. Oesophagitis was most common amongst non-neoplastic lesions making 11.11% (9 out of 19 cases). Barrett’s oesophagus was confirmed in 3.7% cases of. A similar finding was observed by Somani et al. who observed 6% of oesophagitis and 1% Barrett’s oesophagus. Jaynul Islam et al. found 18.18% of oesophagitis and no case of Barrett’s.(Table 4 A)

Gastric biopsy

In the current study, the most common biopsy submitted was gastric biopsy (36.6%) with a male-female ratio of 1.54:1, which was comparable to the study by Puvitha R Duraisamy et al8 in which they received 34.69% gastric biopsy with male-female ratio 1.5:1. The most common age group undergoing gastric biopsy was 6^th decades whereas it was 7^th decades in Jaynul islam et al. study.Gastritis being commonest lesion and adenocarcinoma commonest malignancy(18.54%) in our and Hirachand et al. study(12.33%). Jaynul islam et al. observed adenocarcinoma as the commonest lesion (45. 20%). This disparity may be due to the small sample size of their study. Mean age of malignancy in the present study was 51.82 years in comparison to 60.12 years in Jaynul islam et al study. In the present study, H. pylori positivity was seen in 52.20% cases which is similar to Hirachand et al. (53.42%). These two studies showed a lesser percentage of H pylori positivity than the observed prevalence rate of 80% in India and other developed countries.9 This can be attributed to the irrational use of proton pump inhibitors, Amoxycillin/clarithromycin, metronidazole before taking a biopsy for histopathology. (Table 4 B)

Duodenal biopsy

In the present study mean age of patients with duodenal biopsy was 43.40 years and most common age group involved was 4^th decades in comparison of 49.47 years and 5^th decades in the study by Jaynul Islam et al. The youngest patient was 11 years old male and the oldest patient was 91 years old female. On Histopathologic examination of both showed features of Non-Specific Duodenitis as there was mild increases in intraepithelial lymphocytes and mild oedema in lamina propria. This observation was similar to a study conducted by Hirachand et al. out of 117 cases one case of the duodenal ulcer was noted whereas Hirachand et al. noted 2 cases of ulcers. Jaynul Islam et al. noted 13.33% of cases of malignancy all adenocarcinoma,73.33% cases of the hyperplastic polyp and no case of Duodenitis. These difference can be attributed to the larger sample size of the present case as well as different dietary habits of study groups. In the present study out of 35 (29.41%) suspected cases of celiac disease Anti-Transglutaminase was raised in twelve. Nine cases of them had modified marsh grade III disease. Manjusha Milind Karegar et al observed 28% cases of celiac disease with slight female preponderance.10 The high proportion CD in the present study as compared to the prevalence rate of 1% in general population11 can be attributed firstly to the fact that our study was conducted on the symptomatic patients and secondly to the overlapping features of other conditions like autoimmune enteropathy, tropical sprue and many other with increased IEL and/or villous atrophy and crypt hyperplasia that can mimic Celiac disease on biopsy. Regular follow up, mandatory anti transglutaminase antibodies estimation, repeat biopsy is required to filter out the overlapping conditions.(Table 5 A)

Colorectal biopsy

Colorectal biopsy comprised of 23.4% cases whereas in the comparison groups the study was focused on colonoscopic biopsy. There is male preponderance in all the studies. The mean age of patients of colonic biopsy 50.72yr with maximum cases of the patient was in their sixth decades of life (23.93%). Makaju et al observed mean age of 41.2 years, maximum cases were in the age group of 20-39 years (31.58%).12 Percentage of neoplastic to non-neoplastic cases found to be similar to Abilash et al13 and Makaju R et al. Our study observed that the commonest lesion was adenocarcinoma accounting for 30.76%, comparable to Abilash et al. who reported 21.6% cases of it. Whereas Makaju et al. observed only 11.58% of malignancy. The non-neoplastic polyp in the current study was 10.25%. The most common non-neoplastic lesion was colitis similar to Abilash et al but in discordance with Makaju R et al. They observed non-neoplastic polyps (32.63%) as the commonest lesion. In our study, inflammatory bowel disease was seen in 17.09% of cases with 85% of cases of ulcerative colitis and15% cases of Crohn's disease. These findings were in concordance with studies by Abilash et al. (26.97%). (Table 5 B)