REVIEW

The effective use of gastrointestinalhistopathology: guidance forendoscopic biopsy in thegastrointestinal tract

Neil A Shepherd,1 Roland M Valori2

1Gloucestershire CellularPathology Laboratory,Cheltenham General Hospital,Cheltenham, UK2Department ofGastroenterology, GloucestershireRoyal Hospital, Gloucester, UK

Correspondence toProfessor Neil A Shepherd,Professor of GastrointestinalPathology, GloucestershireCellular Pathology Laboratory,Cheltenham General Hospital,Sandford Road, CheltenhamGL53 7AN, UK;neil.shepherd@glos.nhs.uk

Received 22 October 2013Accepted 17 December 2013Published Online First8 January 2014

▸ http://dx.doi.org/10.1136/flgastro-2013-100412▸ http://dx.doi.org/10.1136/flgastro-2013-100414

To cite: Shepherd NA,Valori RM. FrontlineGastroenterology 2014;5:84–87.

ABSTRACTThis is the first of three articles, published inFrontline Gastroenterology, that providespractical guidance of what to, and what not to,biopsy in the gastrointestinal (GI) tract. Thisinitiative was established by the Endoscopy andPathology Sections of the British Society ofGastroenterology, and the guidance is publishedwith an initial general review (this manuscript),followed by practical guidance on upper GI andlower GI endoscopic biopsy practice. The threearticles are written by experienced operatives,each one by a pathologist and an endoscopist,working in the same hospital/group of hospitals.

Biopsy and histological assessmentprovide a critical adjunct to endoscopicassessment of the gastrointestinal tractand, in diseases such as cancer, coeliacdisease and chronic inflammatory boweldisease, pathological diagnosis remainsthe gold standard. Histological assess-ment of biopsy material is a major part ofthe workload of a histopathology labora-tory in the UK: in large ‘district general’hospitals, it comprises about one quarterof the workload. In 2002 (and revised in2005), the Royal College of Pathologistspublished the results of its workingparty, ‘Histopathology/Cytopathology oflimited or no clinical value’.1 Applicationof the recommendations of the firstedition of the Working Group’s delibera-tions has shown that endoscopic biopsyand histopathological workload can beconsiderably reduced by ensuring thatonly appropriate biopsies are under-taken.2–5 This is not to deny the import-ance of research and the use ofcomprehensive biopsy protocols, such asthe Sydney system for gastritis, in that

type of research.6 7 However, it is criticalthat endoscopists do not practice‘pseudo-research’, and that such biopsiesare only taken according to establishedresearch protocols.Endoscopic practice should not be gov-

erned by the premise that an examinationis not complete without a biopsy.8 Ifthere are no indications for biopsy, espe-cially in upper GI endoscopy, then nobiopsy should be taken.1 For instance, wecan see no indication for routine duo-denal biopsies, outwith the appropriateclinical setting, in a patient, presentingwith, say, dyspepsia. Further, histologicalassessment of GI biopsies is a time-consuming and relatively expensive exer-cise. Routine GI biopsies cost in theregion of £60.00 for pathology depart-ments, not to mention the extra time ittakes to take and process a biopsy in theendoscopy department, and the consum-ables. By contrast, endoscopic tests forHelicobacter, for instance, cost less than£5.00. So, a good example of inappropri-ate use of histology is the biopsy of thestomach in the presence of endoscopic‘gastritis’ or in the absence of endoscopicabnormality. What the endoscopist thinksis gastritis is poorly correlated with thedemonstration of gastritis on histologicalassessment of biopsies.9 The practice ofbiopsying the normal or near-normalstomach has not been shown to increasethe demonstration of neoplasia.10 Thediagnosis of Helicobacter gastritis can beachieved by much cheaper means, andthere is no evidence base, in our view,that the additional features likely to bedemonstrated, such as reactive gastritis,intestinal metaplasia and the grade of

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chronic active gastritis, modifies the subsequent man-agement of the patient.1

Given the gap between recommendations and clin-ical practice, the inexorable increase in demand forgastrointestinal endoscopy and the imperative to usehealthcare resource as effectively as possible, it isessential that we address the challenge of the appro-priateness of endoscopic biopsy for histological ana-lysis. In these three articles, we publish guidance onwhen and what to biopsy during endoscopic proce-dures. The guidance recommends a pragmaticapproach based on the principle that a biopsy shouldonly be taken if it has the potential to materially influ-ence management. It is appreciated that sometimesbiopsies are taken purely for the purpose of excludingcancer: if there is an endoscopic lesion where thediagnosis of neoplasia is possible, then biopsy is, ofcourse, always recommended.In order to rationalise the use of expensive histo-

pathological resource, we need to understand whysome practitioners biopsy more frequently thanothers. Evidence and practical experience indicate thata less experienced endoscopist is more likely to under-take unnecessary biopsies. This probably reflects threekey differences between the experienced and lessexperienced: first, an experienced endoscopist hasmore confidence (through more knowledge andgreater experience), making a positive judgement thatthere is no serious underlying disease. Second, he orshe has a better understanding of whether a biopsymight help management. Third, an experiencedendoscopist is more willing to accept a higher risk ofmissing something. These factors are particularlyapposite for non-medical endoscopists, who are notusually assessing patients with gastrointestinal symp-toms (as opposed to managing them according to pro-tocols), and who are less comfortable with uncertaintyand risk.To help practitioners take fewer biopsies without an

increased risk of missing serious pathology, thereneeds to be clear-cut guidance and ways of enforcingit. In the last 8 years, there has been, appropriately, astrong emphasis on improving the quality of endo-scopic procedures. Some of this has included keypathology-related performance indicators, such asbiopsies of the colon for patients with watery diar-rhoea when endoscopic examination is normal (seeJAG website: http://www.thejag.org.uk). In other cir-cumstances, recommendations are encapsulated innational guidelines, such as the role of biopsies in thediagnosis and surveillance of Barrett’s oesophagus. Ifwe are to deliver the best care within availableresources, all such recommendations within accreditedguidance should, in time, become performance indica-tors. We believe that the current guidance will givegreater clarity to endoscopists and pathologists. For itto be effective, endoscopy teams need to monitoradherence to the guidance (as they currently do for

endoscopy performance indicators), and then act onperformance outside the recommendations. We areconfident that this will lead to fewer biopsies takenduring endoscopic procedures, reducing pathologycosts and improving the productivity of endoscopyunits with shorter endoscopic procedures and lowerconsumption of disposable biopsy forceps.It is appreciated that, in some circumstances, the

evidence base underpinning the recommendations isnot strong. It is also appreciated that, in somepatients, it may be inappropriate to follow the guid-ance. In view of this, it is recommended that endos-copy teams use the recommendations based in thetwo accompanying articles to create local guidancewith performance indicators specific to their owndepartment. When reviewing performance, it isrecommended that there is some leeway given inreviewing individual practice, particularly if the individ-ual has an unusual caseload. We anticipate that thepublication and regular review of locally agreed guid-ance will not just help educate endoscopists but alsoprovide them with the confidence not to biopsy. Anexample of such guidance, widely used in endoscopydepartments in Leeds, and evolving from the RoyalCollege of Pathologists’ ‘Histopathology/Cytopathologyof limited or no clinical value’ working party,1 is givenin table 1.A histological opinion is, like a radiological opinion,

entirely dependent on information about the case andthe questions being asked. To improve the informationprovided to pathologists, it is recommended that eachunit develops, with pathology colleagues, simple guid-ance of what information should be provided on therequest form. Despite, it would seem, some cliniciansbelieving that a pathologist should be given no clinicalor endoscopic details and should assess biopsiesentirely blind, this is quite clearly inappropriate andmisguided. It is also a truism that many cliniciansbelieve that they should be in ‘pathology mode’ whencompleting pathology request forms. This is verymuch not the case. Pathologists prefer clinicians tostay in clinical mode and give accurate clinical detailsand, particularly, endoscopic details. It is extraordin-ary how often the latter is not given. If there are colo-noscopic biopsies and the only clinical details givenare ‘chronic diarrhoea’, is the pathologist to assumethat the colonoscopy is normal? The pathologist canonly make a diagnosis of ‘microscopic colitis’ whenthe colonoscopy is normal (or near normal, as we arelearning) and, therefore, provision of the accurateendoscopic details is critical.Pathologists do not need reminders of what diseases

they should be looking for on request forms. Ifrandom duodenal biopsies are taken, they know fullwell that, most likely, the clinician is suspecting, or isattempting to rule out, coeliac disease, and patholo-gists do not need prompts for diseases they shouldseek. The first author of this treatise has a particular

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aversion to the use of a question mark followed by aputative diagnosis. This gives the pathologist no ideaof the likelihood of the suggested diagnosis. Forinstance, the question mark can, in our experience,mean anything from ‘most unlikely but pleaseexclude’ to ‘definite changes seen at endoscopy’.Indeed, we have evidence from our own practices, toshow that such a practice can have adverseconsequences leading to erroneous diagnoses andinappropriate patient management. Perhaps this is par-ticularly apposite with the oft-seen ‘? dysplasia’written on pathology request forms. The first authorhas seen many examples where dysplasia has beenovercalled, and the more appropriate diagnostic cat-egory ‘mucosa indefinite for dysplasia’ has not beenused, because the pathologist has been swayed by thesuggestion, from clinicians, that dysplasia is likely tobe present.We hope that these articles do, in particular,

provide useful guidance on what to, and what not to,write on pathology request forms. Pathologists muchprefer the provision of accurate clinical and endo-scopic details: ‘Iron deficiency anaemia. Upper GIendoscopy normal.’ is much more suitable than ‘?HP’. A simple solution to the conundrum of ensuringappropriate clinical details is to enclose/attach a copyof the endoscopy report, which will usually have allthe necessary information: presenting symptoms andreason for the procedure, endoscopic findings, therapyand follow-up plans. Indeed, there is evidence fromcentres, in the UK at least, that this is an ever-increasingpractice with the endoscopic report attached to thepathological request form in every case, a policywhich we very strongly endorse. Eventually, with elec-tronic requesting and electronic patient records morewidespread than they are currently, pathologists’ability to access such systems may abrogate the needfor the currently recommended provision of endos-copy reports.Endoscopic practice is undergoing a revolution

with the development of much more accuratevideo-endoscopy, magnifying endoscopy and

techniques such as chromo-endoscopy, auto-fluorescence imaging and narrow band imaging.11–14

It is likely that these techniques will eventually makeredundant random biopsy protocols for diseases suchas Barrett’s oesophagus and chronic inflammatorybowel disease. This will, eventually, create a muchmore appropriate directed biopsy practice for thedetection of neoplasia complicating these diseases andreduce pathological workload. Furthermore, newdevelopments may eventually abrogate the need forhistological assessment in certain situations, perhapsespecially for small colorectal polyps.15

We believe that there is an opportunity to rationalisethe use of gastrointestinal pathology without com-promising the effective management of patients. Werecommend that endoscopy teams work with theirlocal pathologists to create and enforce local guidancebased on the accompanying articles on endoscopicbiopsy practice in Frontline Gastroenterology. Whilewe accept that comprehensive guidance documentssuch as these make for arduous reading in the immedi-acy of the endoscopy room, we would encourage theuse of schemata for biopsy-taking for routine use inendoscopy departments.This guidance represents, to our knowledge, the

first UK-based wide-ranging initiative for endoscopybiopsy practice in the GI tract. In particular, we haveprovided recommendations for the accurate diagnosisof GI pathology, but it also addresses areas wherehistological assessment cannot be justified, especiallybased on relative cost and relative sensitivity and spe-cificity, compared with other diagnostic modalities. Inthat way, it differs from recently published guidelinesin the USA.16 Like those guidelines, our guidance isevidence-based advice that should not be regarded asdefinitive but can be modified according to local prac-tice and protocols.

Acknowledgements With grateful thanks to Dr J I Wyatt andDr A Cairns for the provision of Table 1.

Competing interests None.

Provenance and peer review Not commissioned; externallypeer reviewed.

Table 1 Guidance for biopsy practice used in endoscopy departments in the Leeds area

Biopsy? YES NO

Oesophagus Diagnosis and surveillance of Barrett’s (4 biopsies every 2 cm) Normal oesophagusAny focal lesion or ulcerationWhen the clinical and endoscopic data suggest eosinophilic oesophagitis

Reflux oesophagitis unless ulcerationUltrashort segment Barrett’s

Stomach Any focal lesion Normal stomachUnusual appearance or high suspicion of dysplasia/malignancy(when suspecting malignancy take 8 biopsies from the lesion, avoiding the ulcer base)

Diffuse ‘gastritis’—use CLO test to determineHelicobacter pylori status

Duodenum Diagnose/exclude coeliac disease when clinically indicated(≥3 biopsies in 1 cassette)

‘Duodenitis’ at endoscopy

Colorectal Normal colonoscopy in patients with persistent watery diarrhoea (send 2 cassettes—3biopsies from right side and 3 from left side)

Other normal colonoscopy

Any polyp/other focal lesion Ileal biopsy to demonstrate that the ileum hasbeen reached

Patient with known or genuinely suspected IBD Random rectal biopsy for rectal bleeding.

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15 Ignjatovic A, East JE, Suzuki N, et al. Optical diagnosis ofsmall colorectal polyps at routine colonoscopy (Detect InSpectChAracterise Resect and Discard; DISCARD trial):a prospective cohort study. Lancet Oncol 2009;10:1171–8.

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doi: 10.1136/flgastro-2013-100413January 8, 2014

2014 5: 84-87 originally published onlineFrontline Gastroenterol Neil A Shepherd and Roland M Valori biopsy in the gastrointestinal tracthistopathology: guidance for endoscopic The effective use of gastrointestinal

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