Endoscopic biopsy (Gastrointestinal)

Biopsy

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Tissue biopsy during endoscopy.

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Endoscopic Biopsy (Gastrointestinal) - Comprehensive Information Guide

1. Why is it done?
- Test Overview: A gastrointestinal endoscopic biopsy involves obtaining small tissue samples from the lining of the esophagus, stomach, small intestine, or colon using a specialized endoscope. These samples are examined microscopically to diagnose disease, identify infections, detect malignancy, and assess inflammation.
- Primary Indications: Investigation of chronic or recurrent gastrointestinal symptoms including persistent abdominal pain, chronic diarrhea, unexplained weight loss, or dysphagia (difficulty swallowing)
- Diagnosis of Conditions: Confirmation of inflammatory bowel disease (Crohn's disease, ulcerative colitis), celiac disease, Barrett's esophagus, gastric ulcers, and H. pylori infection
- Cancer Detection: Evaluation of suspicious lesions, masses, or polyps that may indicate gastrointestinal malignancy, including esophageal, gastric, and colorectal cancers
- Infection Assessment: Identification of infectious agents including Helicobacter pylori, viral infections (CMV, HSV), fungal infections, or parasitic infections
- Routine Screening: Surveillance biopsies in high-risk patients, such as those with long-standing Barrett's esophagus or chronic inflammatory bowel disease at risk for dysplasia or cancer
- Therapeutic Purposes: Removal of benign polyps or small lesions during the endoscopic procedure
2. Normal Range
- Normal/Negative Results: Tissue samples show normal histology with intact mucosa, appropriate cellular architecture, absence of inflammation, infection, dysplasia, or malignancy
- Normal Microscopic Features: Regular epithelial cells, normal glandular structures, minimal to no chronic inflammatory cells, normal lamina propria, no metaplasia or dysplasia
- Measurement Units: Biopsy results are descriptive and qualitative, reported as histopathological diagnoses rather than numerical values. Samples are typically described using standardized grading systems for inflammation, dysplasia, and other findings.
- Interpretation Framework: Results are interpreted as: Negative (no pathology), Positive (specific findings consistent with disease), or Atypical/Uncertain (findings that require clinical correlation or additional testing)
- Inflammation Grading: Normal = No inflammation or mild chronic inflammation that is not clinically significant
3. Interpretation
- Inflammatory Findings: Acute or chronic inflammation with increased neutrophils, lymphocytes, or other inflammatory cells suggests inflammatory bowel disease, infectious colitis, or gastritis. Severity is graded as mild, moderate, or severe.
- Infection Identification: Special stains reveal H. pylori (Giemsa, immunohistochemistry), viral cytopathic effects indicating herpes or CMV, fungal elements suggesting candidiasis or histoplasmosis, or parasites
- Dysplasia Grading: Low-grade dysplasia (LGD) shows increased nuclear-to-cytoplasmic ratio and abnormal architecture but maintains some normal features. High-grade dysplasia (HGD) shows marked cytologic and architectural atypia with high risk of progression to cancer.
- Malignancy Findings: Adenocarcinoma, squamous cell carcinoma, or other malignant neoplasms are classified by type, grade (G1-G3), and depth of invasion. Grade 1 (well-differentiated) to Grade 3 (poorly differentiated) indicates prognosis and treatment options.
- Metaplasia Detection: Barrett's esophagus shows intestinal-type metaplasia in the distal esophagus. Intestinal metaplasia in the stomach indicates increased cancer risk. Presence and extent are documented.
- Polyp Classification: Adenomatous polyps carry malignant potential and are graded by villous/tubular architecture and degree of dysplasia. Hyperplastic or inflammatory polyps are generally benign.
- Factors Affecting Results: Sampling location, number of samples, specimen handling, tissue processing, staining techniques, and observer expertise all influence accuracy. Inadequate sampling may produce false-negative results.
- Clinical Significance: Results guide treatment decisions, predict disease prognosis, determine surveillance intervals, and identify patients requiring more aggressive management or specialist referral
4. Associated Organs
- Primary Organs Involved: Esophagus, stomach, duodenum, jejunum, ileum, cecum, colon, and rectum. The gastrointestinal tract is a continuous organ system, and disease in one segment may affect others.
- Inflammatory Bowel Disease (IBD): Crohn's disease (can affect any part of GI tract) and ulcerative colitis (limited to colon and rectum) show characteristic inflammation patterns, crypt distortion, and goblet cell depletion
- Celiac Disease: Biopsy of small intestinal duodenum shows villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes indicating gluten-induced mucosal damage
- Barrett's Esophagus: Esophageal biopsy shows replacement of squamous epithelium with columnar intestinal-type epithelium with goblet cells, indicating chronic acid reflux damage and increased esophageal adenocarcinoma risk
- Gastric Ulcer Disease: Gastric biopsies reveal H. pylori organisms, chronic inflammation, intestinal metaplasia, and dysplasia. H. pylori infection is a precursor to gastric cancer and MALT lymphoma
- Gastrointestinal Malignancies: Esophageal cancer, gastric cancer, and colorectal cancer present with adenocarcinoma, squamous cell carcinoma, or other histologic types. Biopsy establishes diagnosis, type, grade, and aids staging.
- Infectious Complications: Abnormal biopsy results may indicate severe infections leading to sepsis, perforation, stricture formation, or disseminated infection in immunocompromised patients
- Dysplasia-Related Risks: Detection of high-grade dysplasia significantly increases cancer risk, requiring close surveillance or intervention. Low-grade dysplasia requires careful monitoring due to potential progression.
5. Follow-up Tests
- Immunohistochemistry (IHC): Performed when initial biopsy shows dysplasia, malignancy, or uncertain findings. IHC markers identify specific antigens to confirm diagnosis, determine cancer type, and assess prognosis (HER2, ER/PR status).
- Molecular Testing: DNA sequencing or mutation analysis for gastrointestinal malignancies to identify actionable mutations (KRAS, TP53, BRAF) guiding targeted therapy selection
- H. pylori Testing: If biopsy shows H. pylori infection, urea breath test or stool antigen testing confirms active infection. Post-treatment testing verifies eradication 4-6 weeks after antibiotic therapy.
- Repeat Endoscopy with Biopsy: For Barrett's esophagus with low-grade dysplasia: repeat in 3-6 months. For high-grade dysplasia: repeat in 3 months or consider endoscopic ablation. For IBD: surveillance endoscopy every 1-2 years depending on disease activity and dysplasia history.
- Imaging Studies: CT or MRI abdomen/pelvis for staging if malignancy detected. Endoscopic ultrasound (EUS) for T-staging of esophageal or gastric cancers. PET-CT for metastatic workup in advanced disease.
- Serologic Testing: Tissue transglutaminase (tTG) antibodies if biopsy shows villous atrophy suggesting celiac disease. Hepatitis and HIV testing if viral findings present.
- Blood Tests: CBC (complete blood count) to assess for anemia or infection. Metabolic panel and liver function tests to evaluate overall health status and organ function. Inflammatory markers (CRP, ESR) for IBD assessment.
- Specialized Stains: Periodic acid-Schiff (PAS), Congo red, or acid-fast stains if infection or unusual findings present. Electron microscopy rarely used for ultrastructural diagnosis.
- Monitoring Schedule: Surveillance intervals depend on biopsy findings: Normal = routine screening intervals; Inflammation without dysplasia = 1-2 year follow-up; Low-grade dysplasia = 3-6 month follow-up; High-grade dysplasia = 3 month follow-up or intervention; Malignancy = staging and treatment planning.
6. Fasting Required?
- Fasting Status: YES - Fasting is required for upper gastrointestinal endoscopy (esophagus, stomach, duodenum).
- Fasting Duration for Upper Endoscopy: NPO (nothing by mouth) for 6-8 hours before the procedure. Typically, patients should not eat or drink anything after midnight before a morning procedure.
- Lower Endoscopy (Colonoscopy) Preparation: Complete bowel cleansing is required. Patients consume bowel preparation solution (polyethylene glycol or citrate-based solutions) the day before the procedure and follow clear liquid diet starting 24 hours before colonoscopy.
- Medications to Avoid: Anticoagulants (warfarin, apixaban, rivaroxaban) - typically held 3-5 days prior. Antiplatelet agents (aspirin, clopidogrel) - hold per physician guidance. Iron supplements - discontinue 3-5 days before. Certain diabetes medications may need adjustment.
- Medications to Continue: Blood pressure medications, thyroid medications, and most chronic disease medications should be taken with small sip of water on the morning of procedure unless specifically instructed otherwise.
- Pre-procedure Instructions: Arrange for someone to drive you home as conscious sedation is typically used. Avoid alcohol 24 hours before and after. Wear loose, comfortable clothing. Inform endoscopist of allergies, anticoagulation status, and medical conditions.
- Diet Restrictions: For upper endoscopy: clear liquids up to 2 hours before (water, apple juice, tea without milk). For colonoscopy: clear liquids only starting 24 hours before. Avoid red, purple, or blue dyes.
- Post-procedure Care: After procedure, rest until sedation wears off (2-4 hours). Avoid driving, operating machinery, or making important decisions for 24 hours. Resume normal diet gradually starting with clear liquids. Report fever, severe pain, or bleeding immediately.

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