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Multiple sections from multiple endoscopic biopsies allow a more complete microscopic analysis4.
Biopsy from the colon showing thickening of the subepithelial collagen table in collagenous colitis8.2. Raised polypoid lesion in a biopsy from a patient with ulcerative colitis showing microscopic features of dysplasia : DALM9. Multiple biopsies imply a minimum of two samples from each site (Table) This is also true for a diagnosis of collagenous or lymphocytic colitis. Thickening of the subepithelial collagen table in collagenous colitis is indeed not homogeneous. In a recent study at our institute, chromo endoscopy (CE) and narrow band imaging (NBI) were used to detect dysplasia in ulcerative colitis.
Laser scanning endoscopy provides a microscopy-level image without obtaining a biopsy specimen.

The choice of the appropriate fixative is based on the type of tissue being fixed and on projected needs for ancillary tests, such as special stains, immune histochemistry, in situ hybridization, and electron microscopy. Routine Haematoxylin and eosin staining of multiple sections is adequate in most cases but insufficient in particular situations such as a diagnosis of Hirschsprung's disease or metabolic storage disorders.(Fig 3) For such indications freshly frozen tissue for enzyme histochemistry for the demonstration of acetylcholinesterase activity in nerves, or the identification of fat are needed or tissue fixed in glutaraldehyde for transmission electron microscopy. Histochemistry (histological special stains) searching for mucins or other substances, and occasionally electron microscopy and genetic markers can also be applied on biopsy samples. Some studies have found that focally enhanced gastritis is present in up to 20% of paediatric ulcerative colitis patients, suggesting that this type of gastritis is a marker of IBD in general in children. Immune histochemistry for cytokeratin patterns and other markers can help to identify the primary origin if needed.Overall a microscopic diagnosis of polyps (elevated lesions) depends on the type of the lesion and the size and number of biopsies. Inflammatory conditionsIleocolonoscopy is an important tool for the diagnosis of diarrhoea and colitis.
Focal or diffuse basal plasmacytosis is a strong predictor for the diagnosis of IBD, especially ulcerative colitis (occurring in over 70% of the patients).

Structural epithelial changes include the presence of an irregular surface, sometimes called pseudovillous or villiform surface and a disturbed crypt architecture.[72-74]Atypical presentations such as ulcerative colitis with left-sided colitis and peri-appendicular inflammation or caecal patch are occasionally observed. Colonic biopsies from children between 1 and 10 years of age, presenting with new-onset ulcerative colitis show significantly less crypt branching, plasma cells in the lamina propria, cryptitis, crypt abscesses, and epithelial injury when compared with samples from adults. This condition is common after surgery for ulcerative colitis, but can occur also after surgery for other indications. Only when cancer invades the submucosa, it is considered to have the potential to metastasize, although lymphangiogenesis can occur in the mucosa as shown in ulcerative colitis.[89] The established histopathological criteria that determine the treatment options of polypectomy versus subsequent surgical resection because of the risk of residual tumour are the status of the resection margin, the histological grade, lympho-vascular invasion, budding of cells and invasion into the submucosa below the stalk of the polyps but above the muscularis propria.

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