GI Pathology
GI Pathology Report
Patient: MARTINEZ, Robert J. ยท MRN: 00451209 ยท DOB: 03/14/1962
Date of Procedure: 04/17/2026 ยท Endoscopist: Steven G. Johnson, MD
Accession #: SAL-2026-04-001872 ยท Doc ID: 208
Specimen
Location:
Esophagus: middle
Stomach: pylorus
Colon: proximal transverse
Other: Terminal ileum biopsy โ random sampling
Type: mass/tumor
Diagnosis
1. Esophagus, middle โ Reflux esophagitis with mild chronic inflammation.
2. Stomach, pylorus โ Chronic gastritis, H. pylori negative.
3. Colon, proximal transverse โ Tubular adenoma with low-grade dysplasia; margins free.
4. Terminal ileum โ Unremarkable mucosa.
Containers
4 (A: Esophagus, B: Stomach, C: Colon, D: Ileum)
Clinical History
64 y/o male with iron-deficiency anemia and intermittent rectal bleeding x 3 months. Prior colonoscopy 2021 showed 2 tubular adenomas. Family history of CRC (father, dx age 58).
Gross Description
Received in formalin, four labeled containers: (A) Esophagus, mid โ 2 fragments, tan-pink, each 4 mm. (B) Stomach, pylorus โ 3 fragments, tan-white, 3โ5 mm. (C) Colon, proximal transverse โ single sessile polyp, 8 mm. (D) Terminal ileum โ 2 fragments, tan, 3 mm each. All entirely submitted.
Microscopic Description
Sections of the colonic mucosa show preserved crypt architecture with mild chronic inflammatory infiltrate in the lamina propria. Focal areas demonstrate dysplastic glandular changes with nuclear stratification and loss of polarity, consistent with low-grade dysplasia. No high-grade dysplasia or invasive carcinoma identified.
Post Procedure Finding
Patient tolerated procedure well. No immediate complications. Surveillance colonoscopy recommended in 3 years per USMSTF guidelines. Pathology results to be discussed at follow-up visit on 5/2/2026.