There is NO reason to do H. pylori immunostain on every gastric biopsy. We all know (or should know) that you have a virtually 0% chance of finding H. pylori without seeing accompanying inflammatory changes. My institution used to do this, then did an actual in house study and only found 1 case out of over a thousand that looked negative histologically but had a single bacteria c/w H. pylori on stain. That is not medicine, that is pure profit. We stopped doing up-front IHC and only order on inflamed cases where we don't physically see the bacteria on H&E. If you don't see neutrophils, there's minimal if any chance you'll see H. pylori. I don't care what some academic center says.
And since when do academic centers not have financial incentive to over-stain cases? Academic centers are businesses just like the rest of us, and in most of them the salaried pathologists get bonuses and incentive pay depending on volume and profits. They are often some of the worst offenders, as they seem to get a free pass just like people on here are giving them.
Practice medicine, people, that's what you are trained to do. Don't try and line your pockets or you're only going to drive further slashes in reimbursement when you get caught. But thanks in advance for ruining it for the rest of us.
I am a GI fellowship trained pathologist and I vehemently disagree. The studies I have seen on this make my blood boil because they miss the whole of doing these stains (H pylori and Alcian Blue) up front and do not take into account real world pathologists trying to sign out a heavy daily case load instead of an academic pathologist who doesn't deal with a private pathology case load (and yes, I know some academic pathologists whose case loads are really, really large but that is the exception and not the rule).
1) I can tell you from my experience that there are occasional h pylori cases that show little to no inflammatory changes. I have a handful saved up in my "teaching" cases pile that I guarantee would be missed by any pathologist who did not order H pylori up front. I even had a case in training where there was at best minimal inflammation on H&E, h pylori present on the Giemsa, and the attending refused to believe that it was real. The h pylori IHC confirmed their presence. That's h pylori. Intestinal metaplasia is very often very focal and subtle and I have seen that missed by people who just read H&E all the time.
2) Gastroenterologists perform these biopsies specifically to look for H pylori and IM. The H pylori and Alcian Blue stains (when performed by a competent lab) are super sensitive, super specific, and super easy to read in an efficient manner. These diagnoses have actual real world implications and directly affect treament and followup decisions. More importantly, this is the exact reason why these biopsies are being done and they are very common findings on biopsy. Why skimp here to "save a few bucks" and cause (not theorectically, but in actuality) cases to be missed which will adversely affect treatment.
3) Most importantly, and something which NONE of the published studies arguing against upfront H pylori and Alcian Blue stains address, is the issue of pathologist time and fatigue, both physical and mental. Its great that in study A, a pathologist reading x h pylori cases in their spare time at a leisurely pace can spot all the h pylori cases. But do they mention how long it took them to read the cases vs someone using the h pylori IHC stain? A pathologist who is just reading an H&E without an Alcian Blue has to spend AT LEAST double the time reading a to make sure they don't miss intestinal metaplasia that will take them all of 10 seconds to find on an Alcian Blue stain. Heaven forbid there is significant inflammation on the biopsy, because now you quadruple the time looking for H pylori on the H&E which can be found about 5-30 seconds (depending on how many there are) on the H pylori IHC. And if you don't find them, then A) you probably spent 10 minutes looking for them) and B) now you get to waste time ordering the IHC, setting aside the case, then reassembling the case when the IHC comes out the next day.
4) Oh, and by the way, I don't care what these studies allege to show, if one has a partially treated patient with residual h pylori, it will be missed on H&E. Why? a) There will be no indication on the requisition that this patient was treated already. 2) The h pylori will be hiding deep in the glands and will NOT be seen on H&E no matter how hard one looks. 3) The diminished inflammation from treatment will cause the pathologist not to be suspicious and order the IHC.
Maybe those things sound like small potatoes, and they probably are when one is looking at 10 stomach biopsies a day at an academic institution and have a resident and fellow screen the slides before signout. But when one is at a high volume lab and has to be efficient, those little things add up and lead to significantly lower throughput as well as significantly increased physician mental fatigue. If I have to spend 10 minutes on each stomach biopsy instead of 2 minutes with stains ordered up front, that loss of time will add up really really quickly.
All of this is done in the name of "saving money". Yes, it would save money if one looks at it from the perspective of reimbursement. But if, heaven forbid, one actually puts a value on pathologist time, then this is a terrible strategy. The significantly decreased pathologist output coupled with the increased mental fatigue way overshadows the savings from not ordering stains up front. Ordering H pylori IHC and Alcian Blue stains up front on GI biopsies directly causes greater accuracy and increased pathologist throughput. Why would pathologists argue to sacrifice that so they can get paid less?
