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The report showed up in mychart about 10 pm I'm sure the Dr will calling in the morning.  With this  report what am I in for are there any ? I need to ask the Dr when he calls

Thanks  Tony

DIAGNOSIS:

1. Colon, efferent limb, J pouch biopsy

Colonic mucosal biopsy showing severe chronic active colitis and

cryptitis.

Negative for crypt abscesses, granulomas or dysplasia.

 

2. Colon, afferent limb, J pouch biopsy

Colonic mucosal biopsy showing severe chronic active colitis and

cryptitis.

Negative for crypt abscesses, granulomas or dysplasia.

 

3. Rectum, rectal cuff, biopsies:

Rectal mucosal biopsies showing severe chronic active proctitis and

cryptitis.

Negative for crypt abscesses, granulomas or dysplasia.

 

GROSS DESCRIPTION:

1. The specimen is received in formalin labeled with the patient's name

and consists of 3 pieces of tan, irregularly shaped soft tissue which

range in size from 0.3 cm up to 0.4 cm in greatest dimension. The

specimen is entirely submitted in one cassette.

 

2. The specimen is received in formalin labeled with the patient's name

and consists of one piece of irregularly

shaped, tan soft tissue. The

specimen measures 0.3 cm in greatest dimension. The specimen is entirely

submitted in one cassette.

 

3. The specimen is received in formalin labeled with the patient's name

and consists of two pieces of irregularly shaped, tan soft tissue. The

smaller piece measures 0.3 cm and the larger piece measures 0.4 cm in

greatest dimension. The specimen is entirely submitted in one

cassette. MC

 

CPT: 88305 x 3

 

 

Final Diagnosis performed by Maria Pedemonte, MD. Electronically signed

8/28/2016 17:46    

Replies sorted oldest to newest

Looks like "run of the mill" pouchitis and cuffitis to me. It always looks worse than it is because of all the medicalese, but there is no evidence of dysplasia or Crohn's at this point. It does not mean you do NOT have Crohn's though.

Even a perfectly healthy pouch will show some chronic inflammation microscopically.

Jan

Jan Dollar

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