What is the level of mayhem?

This patient attends for Barrett's surveillance
WHAT IS YOUR DIAGNOSIS?

a) Barrett's without dysplasia

A nodule within Barrett's is NEVER 'normal'!

b) LGD

LGD is flat, not nodular!

c) HGD

Good guess! Although your guess actually proved to be wrong

d) IMca

Small crypts + nodule = correct!

e) invasive cancer

Nodule should have been larger and without those small crypt openings

explanation

My 'rules of thumb' when assessing Barrett's is as follows: 
1) crypts look different in a distinct patch but the area is flat = LGD
2) areas of superficial ulcers within the Barrett's = widespread LGD 
3) crypts look different and there is a distinct nodule = HGD
4) crypts are tiny small and there is a nodule = IMca
5) there are no crypts and there is larger nodule = invasive cancer

Of course this isn't fool proof ! After all, it's very difficult to distinguish HGD from IMca even on histology!  However, it gives you a starting point on how to assess Barrett's and what you should enter on that Histopathology request form.  Remember that your pathologists need your help!