Last updated January 11, 2022

Endoscopic Mucosal Tissue Sampling

Tissue sampling recommendations and suggestions

Esophagus

GERD

Targeted biopsies of irregular mucosa, if clinically warranted. (S, L)
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BE

Surveillance of nondysplastic BE: 4-quadrant biopsies every 2 cm with large-capacity forceps for length of Barrett’s mucosa. (S, L)
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Surveillance of BE with LGD: 4-quadrant biopsies every 1-2 cm with large-capacity forceps for length of Barrett’s mucosa. (R, M)
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Surveillance of BE with HGD: 4-quadrant biopsies every 1 cm with large-capacity forceps for length of Barrett’s mucosa. (R, M)
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EoE

  • 2-4 biopsies from proximal esophagus
  • 2-4 biopsies from distal esophagus
  • Biopsies of gastric antrum and duodenum when EG suspected
  • Biopsies should not be placed in Bouin’s preservative
(S, L)
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Infectious esophagitis

Viral esophagitis
  • Multiple biopsies from margin and base of visualized ulcers
  • Specimens should be sent for standard histology, IHC, and possibly viral culture and PCR
(S, L)
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Candidal esophagitis
  • Multiple biopsies of affected area
  • Cytologic brushing complementary to biopsy
(S, L)
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Stomach

H. pylori Infection

Urease test
1-2 biopsies: 5 cm proximal to the pylorus on the lesser curvature near the angularis or on the greater curve opposite the angularis. (S, L)
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A negative urease test result should be confirmed with further testing for H. pylori. (S, L)
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Histologic diagnosis
2 approaches:
  • 3 biopsies: 1 from the angulus corpus-antrum junction, 1 from the greater curvature of the corpus, 1 from the greater curvature of the antrum
(S, L)
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OR
Updated Sydney Protocol
  • 5 biopsies: 1 from antrum the 2-3 cm from the pylorus lesser curvature, 1 from the antrum 2-3 cm from the pylorus greater curvature, 1 from the corpus 8 cm from the cardia lesser curvature, 1 from the corpus 8 cm from the cardia greater curvature, 1 from the angularis
(S, L)
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If H. pylori positive, perform biopsy protocol for EMAG (below). (S, L)
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Environmental metaplastic atrophic gastritis

Best data with 7-12 biopsies: 4-quadrant biopsies from antrum (2–3 cm proximal to pylorus), 2 from the angularis, 4 from the mid corpus (2 lesser curvature, 2 greater curvature), 2 from the cardia. (S, L)
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EMAG protocol should be sufficient for H. pylori histologic diagnosis. (S, L)
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Autoimmune metaplastic atrophic gastritis

Individualize approach. Biopsies directed at ulcers, nodules, polyps, masses to rule out neoplasia. (S, VL)
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Gastric polyps

Solitary polyps

  • Sample (biopsy or polypectomy).
  • Further management determined by histology:
  • Fundic gland polyp: >1 cm should undergo polypectomy
  • Hyperplastic polyp: >0.5 cm should undergo polypectomy
  • Adenomatous polyp: all should undergo polypectomy
(S, L)
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Multiple polyps

  • Largest polyp removed with polypectomy
  • Representative sampling of smaller polyps
  • Further management dependent on histology
(S, L)
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For hyperplastic and adenomatous polyps:

  • Follow EMAG protocol
  • Biopsies of surrounding nonpolypoid mucosa
(S, L)
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Peptic ulcer disease

  • Multiple biopsies from the base and edges of a gastric ulcer when malignancy is suspected or suggested by endoscopic appearance.
  • Cytology may be complementary
(S, L)
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Perform biopsy protocol for H. pylori as above. (S, L)
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Small intestine

Celiac disease, tissue sampling instructions, strength, and evidence grades

4-6 biopsies in total from duodenal bulb and distal duodenum. (S, L)
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Colon

Microscopic colitis

2 approaches:
1. FS:
  • ≥2 biopsies from the transverse colon (if possible)
  • ≥2 biopsies from the sigmoid colon
  • ≥2 biopsies from the descending colon
(S, L)
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OR
2. Colonoscopy:
  • ≥2 biopsies from the right colon
  • ≥2 biopsies from the transverse colon
  • ≥2 biopsies from the descending colon
  • ≥2 biopsies from the sigmoid colon
(S, L)
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A nondiagnostic FS should be followed by colonoscopy with biopsy, pending clinical suspicion. (S, L)
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Inflammatory bowel disease

Initial diagnosis

Ileocolonoscopy: ≥2 biopsies from at least 5 sites, including the ileum and rectum. (S, L)
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If EGD performed for suspected IBD:

  • ≥2 biopsies from the esophagus
  • ≥2 biopsies from the stomach
  • ≥2 biopsies from the duodenum
(S, L)
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Surveillance for dysplasia:

All endoscopically visible lesions should undergo biopsy and/or be removed. (R, H)
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2 approaches:

  1. Chromoendoscopy with pancolonic dye spraying and targeted biopsies.
    Also, biopsies from each colonic segment to assess inflammation.
(R, M)
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OR
  1. Pancolitis§:
  • 4-quadrant biopsies every 10 cm from the cecum to the rectum, for a minimum total 33 biopsy samples
(S, L)
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Nonpancolitis§:
  • 4-quadrant biopsies every 10 cm limited to greatest extent of endoscopic or histologic involvement documented by any colonoscopy
(S, L)
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Suspected pouchitis

  • Multiple biopsies from the pouch and afferent limb
(S, L)
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Miscellaneous

Acute graft-versus-host disease

2 approaches:
1. FS
  • ≥4 standard forceps biopsies from the rectosigmoid
  • ≥4 standard forceps biopsies the from left colon
  • If FS nondiagnostic, proceed to EGD with ≥4 standard forceps biopsies each, from the gastric antrum, gastric body, and duodenum.
  • Distal esophageal biopsies may be considered.
(S, L)
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OR
2. Ileocolonoscopy
  • ≥4 standard forceps biopsies from the terminal ileum
  • ≥4 standard forceps biopsies from the right colon
  • ≥4 standard forceps biopsies from the transverse colon
  • ≥4 standard forceps biopsies from the left colon
  • ≥4 standard forceps biopsies from the rectosigmoid
(S, L)
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* Specimens taken from a given geographic location should be submitted to pathology in their own container.
Recommendation is for a sporadic single fundic gland polyp that is not associated with familial adenomatous polyposis. Although sporadic fundic gland polyps have low to no malignant potential, expert opinion has been to remove fundic gland polyps larger than 1 cm. Withdrawal of a proton pump inhibitor may be considered in patients with fundic gland polyps larger than 1cm.
If H. pylori positive, treatment has been associated with regression of hyperplastic polyps.
§ Consideration should be given to sampling every 5 cm in the distal colon.
|| Although no hemorrhagic complications with biopsy were noted in the prospective literature, they have been reported in a retrospective study. Clinical judgment should be used to reduce number of biopsies if there is thought to be a significant bleeding risk.
¶ Alternatively, pending clinical scenario, flexible sigmoidoscopy/EGD may be performed consecutively during a single endoscopic session.

Recommendation Grading

Overview

Title

Endoscopic Mucosal Tissue Sampling

Authoring Organization

Publication Month/Year

August 1, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Outpatient

Scope

Assessment and screening, Diagnosis, Management

Diseases/Conditions (MeSH)

D004724 - Endoscopy, D020776 - Endoscopes, Gastrointestinal

Keywords

endoscopy, tissue sampling, mucosal tissue sampling

Source Citation

Sharaf, R. N., Shergill, A. K., Odze, R. D., Krinsky, M. L., Fukami, N., Jain, R., … Cash, B. D. (2013). Endoscopic mucosal tissue sampling. Gastrointestinal Endoscopy, 78(2), 216–224. doi:10.1016/j.gie.2013.04.167