The use of routine special stains for upper gastrointestinal biopsies

Helicobacter pylori and intestinal metaplasia (IM) are readily seen in hematoxylin and eosin-stained slides of gastric and/or esophageal biopsies, yet many pathology laboratories perform routine special stains on all of these biopsies. We wished to determine if special stains are necessary for every single gastric and/or esophageal biopsy. We prospectively studied 613 gastric and/or esophageal biopsies from 494 consecutive patients. The slides were stained with hematoxylin and eosin, toluidine blue (TB) for H. pylori, and Alcian blue (AB) for IM. The hematoxylin and eosin slide was classed as positive or negative for H. pylori and IM. Then it was determined if the case needed a TB or AB stain. A total of 436 cases (71.1%) were identified as H. pylori-negative and not needing a TB stain, and none was TB+. A total of 126 (20.6%) of hematoxylin and eosin slides were inconclusive for H. pylori and were regarded as needing a TB stain. Twenty of these (15.9%) were TB+. Fifty-one biopsies (8.3%) were regarded as H. pylori+ on hematoxylin and eosin; the TB stain was also positive in 49. IM was present in 113 (18.4%) hematoxylin and eosin biopsies. Hematoxylin and eosin slides were IM-negative in 498 cases (81.2%). The AB stain revealed rare goblet cells in 3 of 498 cases (0.6%). Only one of those biopsies was esophageal, and that had one goblet cell that was missed on hematoxylin and eosin. Only 2 (0.3%) were regarded as needing an AB stain. We conclude that routine special stains for all gastric and/or esophageal biopsies are not required, and hematoxylin and eosin assessment combined with selective ordering of these stains will identify virtually all cases of H. pylori gastritis and intestinal metaplasia.