GI Pathology Report

Patient: MARTINEZ, Robert J. · MRN: 00451209 · DOB: 03/14/1962
Date of Procedure: 04/17/2026 · Endoscopist: Steven G. Johnson, MD
Accession #: SAL-2026-04-001872 · Doc ID: 208

Specimen

Location:
  Esophagus: middle
  Stomach: pylorus
  Colon: proximal transverse
  Other: Terminal ileum biopsy — random sampling
Type: mass/tumor

Diagnosis

1. Esophagus, middle — Reflux esophagitis with mild chronic inflammation.
2. Stomach, pylorus — Chronic gastritis, H. pylori negative.
3. Colon, proximal transverse — Tubular adenoma with low-grade dysplasia; margins free.
4. Terminal ileum — 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 — 2 fragments, tan-pink, each 4 mm. (B) Stomach, pylorus — 3 fragments, tan-white, 3–5 mm. (C) Colon, proximal transverse — single sessile polyp, 8 mm. (D) Terminal ileum — 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.