Reading Your Pathology Report

Biopsy results can feel dense and technical. This guide explains the most important words found in IBD pathology reports and what they usually mean. It focuses on three ideas: chronicity, granulomas, and dysplasia. Understanding these terms helps families follow care plans, ask focused questions, and know when further tests or closer surveillance may be needed.

Key takeaways

• “Chronicity” means long-standing injury patterns that support an IBD diagnosis.

• Granulomas that are away from injured crypts suggest Crohn’s disease, but their absence does not rule it out.

• Dysplasia is precancer change. Grades are negative, indefinite, low grade, or high grade.

• Visible dysplasia is often managed with complete endoscopic removal. Invisible dysplasia needs expert review and close follow-up.

• Pathology must be interpreted together with scope findings, imaging, and symptoms.

How pathologists read IBD biopsies

Pathologists study tiny tissue samples from the bowel. The report describes injury patterns, where inflammation sits, and whether the changes look short term or long term. Most reports comment on activity (how inflamed it is today) and chronicity (evidence of older damage).

Common phrases include “active colitis,” “chronic active colitis,” or “quiescent chronic colitis.” Active means neutrophils are present. Quiescent means little current inflammation, but older scarring patterns remain. The report may also note distribution, such as left colon only or patchy areas, which helps separate ulcerative colitis from Crohn’s when combined with endoscopy.

“Chronicity”: what it means

• Chronicity signals long-standing inflammation rather than a brief infection or a drug effect.

• Clues include:

• Architectural distortion of crypts (branching or irregular shapes).

• Basal plasmacytosis (immune cells at the base of the mucosa).

• Paneth cell metaplasia in the left colon (cell type appearing where it usually does not).

• Crypt atrophy or shortened crypts.

Why it matters:
- These features support IBD over a single short-lived insult. They do not, on their own, prove Crohn’s versus ulcerative colitis.
- When symptoms are quiet but chronicity remains, the disease may be in histologic remission or near remission. Care teams use this information with fecal calprotectin, blood tests, and scope views to judge control.

Helpful terms:
- Acute colitis: short-term injury, often infections or medication related.
- Chronic active colitis: chronicity is present plus current neutrophil activity.
- Quiescent chronic colitis: chronicity without current activity.

Granulomas: when they suggest Crohn’s

• A granuloma is a small cluster of specialized immune cells. In IBD, pathologists look for non-necrotizing granulomas.

• Granulomas that are well formed and away from an injured crypt or surface erosion support Crohn’s disease. This pattern is uncommon in ulcerative colitis.

• Not every granuloma points to Crohn’s. Granulomas next to a ruptured crypt (a “crypt injury granuloma” or mucin granuloma) can occur in ulcerative colitis or from local injury. Infections and other conditions can also form granulomas.

What usually happens next:
- If granulomas are present, the report may note special stains or tests to exclude infections. The gastroenterologist correlates the finding with scope appearance, imaging, and symptoms. Absence of granulomas does not rule out Crohn’s.

Dysplasia: precancer changes in IBD

• Dysplasia means cells look abnormal under the microscope in a way that predicts higher cancer risk. In IBD, grades are:

• Negative for dysplasia.

• Indefinite for dysplasia (changes unclear, often due to active inflammation).

• Low-grade dysplasia (LGD).

• High-grade dysplasia (HGD).

Visible versus invisible:
- A lesion may be visible during colonoscopy (polypoid or flat) or found only on random biopsies (invisible).
- Well-defined visible lesions can often be completely removed endoscopically. The pathology may report whether margins are clear, which supports cure of that lesion.
- Invisible dysplasia usually leads to repeat colonoscopy with enhanced imaging (often dye-spray chromoendoscopy) and review by an expert gastrointestinal pathologist.

How grade guides care:
- Indefinite often triggers optimization of inflammation control and repeat high-quality surveillance within months.
- LGD requires individualized decisions. Single, clearly resected lesions may lead to closer surveillance. Multifocal or unresectable LGD can prompt surgery discussions.
- HGD signals a high risk for cancer. If HGD is not completely resectable, colectomy is usually recommended.

Putting it together: translating common phrases

Questions to ask the care team

• Did the report show chronicity, and how does that align with the scope findings?

• Were granulomas present, and if so, were infections ruled out?

• If dysplasia was found, was it visible and completely resected?

• What is the recommended surveillance interval based on these results?

• Should an expert GI pathologist review the slides?

FAQs

Can chronicity appear even when symptoms are mild?

Yes. Chronicity records the history of injury. Symptoms can be quiet while older scarring patterns remain. Treatment still aims for ongoing mucosal healing.

Does a lack of granulomas mean it is not Crohn’s?

No. Many confirmed Crohn’s cases never show granulomas. Classification relies on the whole picture, including scope and imaging.

How soon is follow-up after “indefinite for dysplasia”?

Often within 3 to 6 months, after calming active inflammation. Timing depends on the overall risk and endoscopic quality.

Is the old term DALM still used?

The field now favors describing a visible lesion’s appearance and whether it is fully resectable, rather than the older DALM label. This approach better guides management.