The gastrointestinal (GI) tract is one of the most frequently affected organ systems by a wide spectrum of inflammatory, infectious, premalignant, and malignant disorders. Diseases involving the esophagus, stomach, small intestine, colon, rectum, and anal canal constitute a significant proportion of hospital admissions and contribute substantially to global morbidity and mortality. Early and accurate diagnosis of these lesions is essential because many gastrointestinal diseases are potentially curable when detected at an early stage. Endoscopy has revolutionized the diagnosis of GI diseases by allowing direct visualization of mucosal abnormalities and targeted tissue sampling for histopathological examination.^[1]

Histopathological evaluation of endoscopic biopsies remains the gold standard for the diagnosis of gastrointestinal lesions. It not only confirms the nature of the lesion but also differentiates inflammatory, infectious, dysplastic, and neoplastic conditions. In addition, histopathology provides valuable information regarding tumor type, grade, extent of dysplasia, and other prognostic features that guide clinical management. The increasing availability of upper gastrointestinal endoscopy and colonoscopy has led to a marked rise in the number of endoscopic biopsy specimens received in pathology laboratories.^[2]

Globally, gastrointestinal cancers account for nearly one-fourth of all cancer cases and more than one-third of cancer-related deaths. Gastric, colorectal, and esophageal cancers together represent a major public health burden. In India, the incidence of gastrointestinal malignancies has shown a steady increase owing to changing dietary habits, tobacco use, alcohol consumption, obesity, Helicobacter pylori infection, inflammatory bowel disease, and an aging population. Timely histopathological diagnosis of premalignant lesions and early-stage cancers significantly improves patient survival through appropriate therapeutic interventions.^[3]

Apart from malignant lesions, endoscopic biopsies frequently reveal various benign conditions such as chronic gastritis, Helicobacter pylori-associated gastritis, Barrett's esophagus, peptic ulcer disease, inflammatory bowel disease, microscopic colitis, polyps, celiac disease, and infectious lesions. Recognition of these entities is equally important because many have malignant potential or require long-term surveillance. Therefore, systematic histopathological evaluation plays a pivotal role in patient care.^[4]

A comprehensive assessment of the histopathological spectrum of gastrointestinal biopsies provides valuable epidemiological information regarding the prevalence and distribution of various GI diseases in a particular geographical region. Such studies also help clinicians understand disease trends, identify high-risk populations, improve diagnostic accuracy, and formulate preventive strategies. Furthermore, retrospective and prospective analyses enable comparison of disease patterns over time and facilitate quality improvement in diagnostic pathology services.^[5]

AIM

To study the histopathological spectrum of endoscopic gastrointestinal tract biopsies received over a five-year period at a tertiary care centre.

OBJECTIVES

1. To evaluate the histopathological spectrum of endoscopic biopsies from different regions of the gastrointestinal tract.
2. To determine the age-wise, sex-wise, and site-wise distribution of gastrointestinal lesions.
3. To classify gastrointestinal lesions into non-neoplastic and neoplastic categories and analyze their histomorphological patterns.

Source of Data The present study was conducted using endoscopic gastrointestinal tract biopsy specimens received in the Department of Pathology from the Department of Gastroenterology and General Surgery of the tertiary care teaching hospital. Both retrospective and prospective biopsy specimens were included. Relevant demographic, clinical, endoscopic, and histopathological details were obtained from pathology requisition forms, hospital records, and laboratory registers. Study Design A hospital-based retrospective and prospective observational descriptive study. Study Location The study was conducted in the Department of Pathology, Basaveshwar Teaching and General Hospital attached to M.R. Medical College, Kalaburagi. Study Duration The study was conducted over a period of five years, comprising three years of retrospective analysis and two years of prospective analysis, from 1st September 2017 to 31st August 2022. Sample Size A total of 357 endoscopic gastrointestinal tract biopsy specimens received during the study period were included. Sample size = 357 Inclusion Criteria • All endoscopic biopsy specimens obtained from the gastrointestinal tract. • Biopsies from the esophagus, gastroesophageal junction, stomach, duodenum, ileum, colon, rectum, and anal canal. • Biopsies from patients of all age groups. • Biopsies from both male and female patients. • Adequately preserved biopsy specimens with complete histopathological details. Exclusion Criteria • Autolyzed biopsy specimens. • Inadequate or insufficient biopsy material. • Poorly preserved specimens unsuitable for histopathological interpretation. • Repeat biopsies from the same lesion without additional diagnostic information. Procedure and Methodology After obtaining approval from the Institutional Ethics Committee, all eligible endoscopic biopsy specimens received during the study period were included. Clinical information including age, sex, presenting complaints, endoscopic findings, and biopsy site was recorded from the pathology requisition forms and hospital records. Each biopsy specimen was examined grossly, and the size, number, color, consistency, and adequacy of tissue fragments were documented. Entire biopsy specimens were processed routinely. Histopathological examination was performed using hematoxylin and eosin-stained sections. Lesions were categorized into inflammatory, infectious, premalignant, benign neoplastic, and malignant lesions based on standard histopathological criteria. Malignant lesions were further classified according to their histological subtype and degree of differentiation using the latest WHO Classification of Digestive System Tumours. All microscopic findings were independently reviewed by experienced pathologists, and the final diagnosis was recorded. Histopathological findings were correlated with demographic characteristics and biopsy site. Sample Processing All biopsy specimens were immediately fixed in 10% neutral buffered formalin for adequate fixation. Tissue processing was performed using standard paraffin embedding techniques. Paraffin blocks were sectioned at 4–5 μm thickness using a rotary microtome. Sections were stained routinely with Hematoxylin and Eosin (H&E) stain. The stained slides were examined under light microscopy. Special stains and ancillary investigations were performed whenever indicated to establish the final diagnosis. Statistical Methods The collected data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) version 25.0. Descriptive statistics were expressed as frequencies, percentages, mean, and standard deviation. Associations between categorical variables were analyzed using the Chi-square test or Fisher's exact test whenever appropriate. Continuous variables were compared using the Student's t-test. A p-value <0.05 was considered statistically significant. Data Collection Data were collected using a structured proforma that included: • Patient age • Gender • Hospital registration number • Clinical presentation • Endoscopic findings • Site of biopsy • Gross findings • Histopathological diagnosis • Classification of lesions • Histological subtype • Tumor differentiation (where applicable) The collected data were compiled, verified, coded, and analyzed to determine the histopathological spectrum and distribution of gastrointestinal lesions.

Table 1: Demographic profile of study participants (N = 357)

Table 2: Distribution of endoscopic biopsies according to anatomical site (N = 357)

Table 3: Age-wise, sex-wise and site-wise distribution of gastrointestinal lesions (N = 357)

Table 4: Distribution of gastrointestinal lesions according to histopathological category (N = 357)

The present five-year retrospective and prospective study evaluated the histopathological spectrum of 357 endoscopic gastrointestinal tract biopsies. The study demonstrated that gastrointestinal lesions were encountered predominantly among middle-aged and older adults, with a significant male predominance. Upper gastrointestinal tract biopsies were substantially more frequent than lower gastrointestinal tract biopsies, the stomach being the commonest individual site. Histopathologically, non-neoplastic lesions constituted the majority, although a considerable proportion of specimens showed neoplastic pathology, particularly malignant epithelial tumours. Demographic profile The mean age of the patients in the present study was 54.34 ± 15.28 years, with the largest proportion belonging to the 51–60-year age group (26.05%), followed by the 41–50-year (22.69%) and 61–70-year (21.57%) age groups. Thus, approximately 70% of the patients were between 41 and 70 years of age. The significant variation across age groups (χ²=148.72, p<0.001) suggested that gastrointestinal lesions requiring biopsy were mainly concentrated in middle-aged and elderly individuals. These findings were closely comparable with those of Machiwal et al. (2022)[1], who reported a mean age of 51.91±18.86 years and observed the highest incidence of gastrointestinal lesions in the 51–60-year age group. Their results support the present observation that the sixth decade is a common period for clinically significant gastrointestinal pathology. Siddiqui et al. (2020)[2], in their five-year study of 556 gastrointestinal biopsies, also found that most lesions occurred in the adult and geriatric age groups, with upper gastrointestinal biopsies predominating across age categories. Contractor et al. (2024)[3] observed that the maximum number of upper gastrointestinal lesions occurred among patients aged 46–55 years, followed by those aged 66–75 years. Their findings broadly corresponded with the clustering of cases between 41 and 70 years in the present study. Hussain et al. (2015)[4], Sheikh et al. (2015)[5], Srivastava and Garg (2018)[6], and Sharma et al. (2019)[7] similarly reported that most endoscopic upper gastrointestinal lesions occurred after the fourth decade of life. The higher frequency of gastrointestinal lesions among older patients may be related to cumulative exposure to tobacco, alcohol, dietary carcinogens, Helicobacter pylori infection, medications, gastroesophageal reflux, chronic inflammation and age-related mucosal changes. The gradual accumulation of genetic and epigenetic abnormalities also increases the probability of dysplastic and malignant transformation with advancing age. Nevertheless, the presence of 18 cases below 30 years in the present study indicates that clinically important gastrointestinal pathology is not restricted to the elderly. Males constituted 229 (64.15%) cases and females constituted 128 (35.85%), producing a male-to-female ratio of approximately 1.8:1. Male predominance was statistically significant (χ²=28.60, p<0.001). This observation was almost identical to that of Contractor et al. (2024)[3], who reported a male-to-female ratio of 1.7:1. Machiwal et al. (2022)[1] reported a ratio of 1.46:1, while several other Indian studies also documented a greater frequency of endoscopic gastrointestinal biopsies among men.[4-9] Male predominance may reflect greater exposure to tobacco and alcohol, occupational and dietary factors, higher prevalence of some gastrointestinal malignancies among men, and possible differences in healthcare-seeking and referral patterns. Anatomical distribution of endoscopic biopsies The stomach was the most frequently biopsied anatomical site in the present study, accounting for 124 (34.73%) specimens. It was followed by the esophagus with 88 (24.65%) biopsies and the colon with 74 (20.73%). Duodenal biopsies accounted for 8.96%, rectal biopsies for 5.04%, gastroesophageal-junction biopsies for 4.48%, anal canal biopsies for 0.84% and ileal biopsies for 0.56%. The marked variation in the distribution of biopsy sites was statistically significant (χ²=239.84, p<0.001). The predominance of gastric biopsies was consistent with Siddiqui et al. (2020)[2], who found that the stomach was the commonest biopsy site among adults, followed by the duodenum. The authors also cited studies in which gastric biopsies constituted approximately 56–65% of gastrointestinal biopsies. Veerendrasagar and Nandish (2020)[8] and Meshram et al. (2020)[9] similarly reported a high proportion of gastric biopsies, reflecting the frequent occurrence of gastritis, gastric ulceration, dyspepsia and suspected gastric neoplasia. Koirala et al. (2024)[10] studied 155 upper gastrointestinal biopsies and reported that 80% were non-neoplastic and 20% were neoplastic. Although their study was limited to the upper gastrointestinal tract, it similarly demonstrated the high diagnostic contribution of gastric and other upper gastrointestinal biopsies. In contrast, Contractor et al. (2024)[3] found the esophagus to be the commonest upper gastrointestinal site, accounting for 48% of 104 biopsies. The difference from the present study may be due to regional variation in disease prevalence, endoscopy referral practices, dietary and lifestyle factors, and differences in the inclusion of lower gastrointestinal specimens. Among lower gastrointestinal sites, the colon accounted for 74 biopsies and represented 20.73% of the complete study population. Bhowmik et al. (2023)[11] studied 65 lower gastrointestinal biopsies and reported chronic nonspecific colitis as the predominant non-neoplastic lesion, while adenocarcinoma accounted for 80% of malignant lower gastrointestinal lesions. Mohapatra et al. (2020)[12] and Kumawat et al. (2021)[13] also described a broad spectrum of inflammatory, polypoidal, dysplastic and malignant lesions in colonoscopic biopsies. The low frequency of ileal and anal canal biopsies in the present study probably reflected the relatively selective indications for sampling these sites. Distribution according to upper and lower gastrointestinal regions Upper gastrointestinal tract specimens constituted 260 (72.83%) biopsies, whereas lower gastrointestinal tract specimens constituted 97 (27.17%). The difference was highly significant (χ²=97.64, p<0.001), demonstrating a clear predominance of upper gastrointestinal lesions. This finding agreed with Siddiqui et al. (2020)[2], who reported that upper gastrointestinal biopsies outnumbered lower gastrointestinal biopsies in paediatric, adult and geriatric populations. Sahu et al. (2019)[14], Machiwal et al. (2022)[1] and other hospital-based studies also reported a higher frequency of upper gastrointestinal biopsies.[4,5,7,8] The greater frequency of upper gastrointestinal biopsy may be attributable to the high prevalence of dyspepsia, gastritis, peptic ulcer disease, reflux-related disorders, dysphagia and suspected upper gastrointestinal malignancy. Upper gastrointestinal endoscopy is also widely available, relatively rapid and commonly employed as an early investigation for persistent upper abdominal symptoms. The lower proportion of lower gastrointestinal biopsies should not be interpreted as a lower clinical importance of lower gastrointestinal diseases. Colonoscopic biopsy remains essential for diagnosing inflammatory bowel disease, microscopic and nonspecific colitis, colorectal polyps, adenomas and carcinoma. Bhowmik et al. (2023)[11] emphasized that colonoscopy combined with histopathological biopsy is an established diagnostic procedure for inflammatory, premalignant and malignant lower gastrointestinal conditions. Differences in upper-to-lower gastrointestinal ratios between studies may depend on patient selection, institutional referral patterns, accessibility of colonoscopy and local screening practices. Histopathological classification Non-neoplastic lesions were the predominant histopathological category in the present study, accounting for 254 (71.15%) cases. Neoplastic lesions accounted for 103 (28.85%) cases. Of these, 17 (4.76%) were benign neoplastic lesions, 8 (2.24%) were malignant mesenchymal tumours, including gastrointestinal stromal tumours, and 78 (21.85%) were malignant epithelial tumours or carcinomas. Both the overall histopathological distribution (χ²=286.91, p<0.001) and the difference between neoplastic and non-neoplastic lesions (χ²=63.82, p<0.001) were statistically significant. The predominance of non-neoplastic lesions was consistent with Machiwal et al. (2022)[1], who found that non-neoplastic lesions were more frequent than neoplastic lesions and that inflammatory pathology was the commonest diagnostic category. Siddiqui et al. (2020)[2] also found benign lesions to be more frequent across all age groups, accounting for 76% of biopsies among adults and 61% among geriatric patients. Their study reported that nonspecific inflammation was particularly frequent in gastric and colonic biopsies. Koirala et al. (2024)[10] reported non-neoplastic lesions in 80% of upper gastrointestinal biopsies and neoplastic lesions in 20%, which was comparable with the predominance of non-neoplastic pathology in the present study. Contractor et al. (2024)[3] observed a smaller difference, with non-neoplastic lesions accounting for 52.8% and neoplastic lesions for 47.1%. Their comparatively higher neoplastic proportion was mainly attributable to the large number of esophageal biopsies and squamous cell carcinomas in their series. Bhowmik et al. (2023)[11] similarly reported that non-neoplastic lesions were more frequent than neoplastic lesions in lower gastrointestinal biopsies, with chronic nonspecific colitis constituting 43% of cases. Veerendrasagar and Nandish (2020)[8], Alghamdi et al. (2020)[15], Kumawat et al. (2021)[13] and Sharma et al. (2019)[7] also demonstrated a predominance of inflammatory and other non-neoplastic disorders. Although non-neoplastic lesions represented the majority, carcinomas comprised 21.85% of all biopsies in the present study and formed the largest neoplastic subgroup. This is clinically important because endoscopic biopsy provides tissue confirmation of malignancy and permits histological typing and grading. Machiwal et al. (2022)[1] reported malignant lesions as the second most frequent category after inflammatory lesions. Siddiqui et al. (2020)[2] noted that squamous cell carcinoma was the commonest esophageal malignancy and adenocarcinoma was the predominant gastric malignancy. Similar findings were documented by Maiti et al. (2018)[16], who evaluated upper gastrointestinal malignancies diagnosed through endoscopic biopsy. The 8 malignant mesenchymal tumours identified in the present study represented 2.24% of all specimens. Such lesions are less common than epithelial malignancies and often require immunohistochemistry for definitive classification, particularly for distinguishing gastrointestinal stromal tumours from leiomyogenic, schwannian and other spindle-cell lesions. The relatively small proportion of benign neoplastic lesions may also reflect the fact that some benign polyps are removed by polypectomy rather than sampled through conventional mucosal biopsy.

The present five-year retrospective and prospective study comprehensively evaluated the histopathological spectrum of 357 endoscopic gastrointestinal tract biopsy specimens received at a tertiary care centre. The study demonstrated that gastrointestinal lesions were most commonly encountered in the fifth and sixth decades of life, with a significant male predominance. The stomach was the most frequently biopsied anatomical site, followed by the esophagus and colon, while the upper gastrointestinal tract accounted for nearly three-fourths of all biopsy specimens. Histopathological examination revealed that non-neoplastic lesions constituted the majority of gastrointestinal biopsies, predominantly representing inflammatory and chronic benign conditions. However, a substantial proportion of biopsies showed neoplastic lesions, among which carcinomas were the most common malignant tumors. The study highlights that endoscopic biopsy, combined with meticulous histopathological evaluation, remains the gold standard for diagnosing gastrointestinal diseases, differentiating benign from malignant lesions, and guiding appropriate clinical management. The findings also provide valuable epidemiological information regarding the regional distribution of gastrointestinal lesions and emphasize the importance of early endoscopic evaluation and tissue diagnosis for improving patient outcomes.

LIMITATIONS OF THE STUDY

1. The study was conducted at a single tertiary care centre, which may limit the generalizability of the findings to the broader population.
2. Clinical follow-up and long-term patient outcomes were not available for all cases.
3. Histopathological diagnosis was based primarily on routine hematoxylin and eosin staining, while advanced molecular techniques were not performed routinely.
4. Immunohistochemical and molecular investigations were not undertaken for all lesions and were reserved only for selected cases where indicated.
5. Correlation with radiological findings and detailed endoscopic grading was not available in every patient.
6. Referral bias inherent to a tertiary care institution may have resulted in a relatively higher proportion of complex and malignant lesions.

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