Table 2.

Summary of recommendations for biopsies in lower endoscopy.

Disease	Recommendations	Comments
Microscopic colitis	Colonoscopy –Two or more biopsies from the ascending colon –Two or more biopsies from the transverse colon –Two or more biopsies from the descending colon –Two or more biopsies from the sigmoid colon Or –At least three to four biopsies from both the right and left colon	–Biopsies from the distal colon and rectum does not always reveal diagnostic findings –If a previous flexible sigmoidoscopy is not diagnostic and the clinical suspicion is high, a colonoscopy should be performed
Inflammatory bowel disease (diagnosis)	Ileocolonoscopy –Two or more biopsies from five different locations, including the ileum and rectum Upper endoscopy –Two ou more biopsies from the esophagus, stomach and duodenum	–In the presence of macroscopic changes, biopsies should be performed in the affected areas and in the apparently normal mucosa
Inflammatory bowel disease (screening for dysplasia)	Chromoendoscopy (targeted biopsies) –Additional biopsies from all segments of the colon to assess the presence and degree of inflammation Random biopsies –Pancolitis: biopsies from the four quadrants each 10 cm –Segmental colitis: biopsies from the four quadrants each 10 cm limited to involved areas in previous examinations	–The ileocecal valve should not be biopsied if macroscopically normal
Pouchitis	–Multiple biopsies from the pouch and afferent loop
Colonic polyps	–Small polyps (<5 mm) can be removed with biopsy forceps –Larger polyps (>2.5 cm) should be removed by polypectomy/mucosectomy	–Biopsies from polyps with a high probability of being removed may lead to submucosal fibrosis and fix lesions that were previously deployable
Acute graftversushost disease	Flexible sigmoidoscopy –Four or more biopsies from the rectum/sigmoid and four or more biopsies from the left colon Ileocolonoscopy –Four or more biopsies from the terminal ileum, ascending colon, transverse colon, descending colon e rectum/sigmoid colon.	–The rectum and distal colon are the locations with the highest sensitivity –In case of non-diagnostic flexible sigmoidoscopy, an upper endoscopy should be performed with four or more biopsies from the gastric body, antrum and duodenum.