10/6- Esophageal Pathology Flashcards
Describe the anatomy of the esophagus
- Length
- Muscle
- Sphincters
- Lyers
- 25 cm long hollow tube (40 cm distance form incisors to GE junction)
- Upper 1/3 = striated muscle; middle third is mixed and lower 1/3 is only smooth muscle
- Upper and lower esophageal sphincters are functional
- Has no serosa; rapid mediastinal spread of invasive lesions
What are 3 narrow points in the esophagus?
- What can occur here?
- Upper sphincter
- Behind heart
- Lower sphincter
Can give sensation of an object tin the esophagus
Label the layers
What is seen here?
- Brush cell layer
- Lamina propria
T/F: The esophagus is surrounded by a rich submucosal venous plexus?
True
What is a hiatal hernia?
- Epidemiology: kids/adults
Separation of the diaphragmatic crura and protrusion of stomach into thorax through the gap
- Congenital hiatal hernias usually in infants and children
- Symptomatic in fewer than 10% of adults; generally associated with other causes of LES incompetence
What are symptoms of a hiatal hernia?
- Heartburn and regurgitation of gastric juices
Similar to gastroesophageal reflux disease (GERD)
What is infectious esophagitis?
- Important cause of esophagitis, especially in immunocompromised
- Most common acute forms are from viruses and fungi
- Bacterial esophagitis may occur in pts with systemic and upper respiratory infection (rarely biopsied)
Describe fungal esophagitis?
- Etiology
- Demographic
- Symptoms
- Most commonly from Candida albicans and Candida tropicalis
- Primarily in pts with underlying disease (may be found in healthy pts)
Symptoms: dysphagia and odynophagia
- Some are asymptomatic; incidental finding at esophagoscopy performed for other reasons (esp in elderly)
What is seen here?
Infectious esophagitis
- White plaques of fibrinopurulent exudate
Which is worse, Candida albicans or tropicalis?
- C tropicalis is more virulent than C. albicans
- Increased potential for tissue invasion
What is required for diagnosis of Candida esophagitis?
Yeast and psuedohyphae should be detected within tissue
- In immunosuppressed patients: only minimal inflammation
- Special stains (silver stain, periodic acid–Schiff [PAS]) should be used to detect small numbers of invasive fungal forms
T/F: Candida is part of the normal flora of the GIT
True
What is a good drug to treat Candida esophagitis?
Fluconazole (Diflucan)
- Safe and well tolerated
(Itraconazole and ketoconazole)
What is seen here?
Candida yeasts within cell layers (not just contamination from oral cavity)
What is seen here?
What can cause viral esophagitis?
- Herpes simplex
- Varicella-zoster
- CMV
- HIV
Most commonly in immunosuppressed patients
- AIDS
- Prior chemotherapy
- Organ transplantation
What are symptoms of viral esophagitis?
- Odynophagia
- Dysphagia
- Epigastric pain
- Fever
- Upper GI bleeding
Some are asymptomatic
Coexistent ____ is found in 1/4 of patients with viral esophagitis
Coexistent herpes labilais and oropharyngeal ulcers are found in 1/4 of patients with viral esophagitis
What is seen with herpetic ulcers in the esophagus?
- It acts as a portal of entry for other pathogens… frequently associated with herpetic pneumonitis
- Endoscopically: shallow and sharply punched out ulcer surrounded by relatively normal-appearing mucosa
What is the pathology of herpetic ulcers?
- Characteristic herpetic inclusion bodies are limited to the squamous epithelial cells, margin of ulcer
- Cowdry A intranuclear viral inclusion bodies, ground-glass nuclei, nuclear molding, multinucleated giant cells and ballooning degeneration of infected cells
- Herpes simplex type I is the most common cause of herpetic esophagitis
- Immunohistochemical staining and in situ hybridization
What is seen here?
Multiple fragments of necro-inflammatory material (ulcer)
What is seen here?
- Chromatin pattern of a normal lymphocyte
- Ground glass chromatin in cells that are infected by virus
What is seen here?
- Margination of chromatin to the periphery
- Molding of nuclei
- Multinucleation
- Necroinflammatory debris (ulcer)
- Ground glass appearance of nuclei
What is seen here?
HSV immunohistochemical stain
What is reflux esophagitis?
- Prevalence
- Causes
- Common chronic condition, esp in Western countries
- Estimated prevalence: 20-40%
- Prolonged and repeated contact of esophageal epithelium with gastric and duodenal contents
- Pepsin, bile, gastric acid and duodenal content: injury to esophageal mucosa.. inflammation and proliferative response
What are predisposing factors to reflux esophagitis?
Decrease lower esophageal sphincter tone
- Alcohol and tobacco use
Increase abdominal pressure
- Obesity
- Hiatal hernia
- Delayed gastric emptying
- Increased gastric volume
Most of the time no definitive cause
What is the morphology of reflux esophagitis?
- Endoscopy
- Mild GERD
- More significant disease
Endoscopy
- Erosion, ulcer or stricture
- Hyperemia (redness) or normal mucosa in up to 60% of symptomatic patient
Mild GERD: unremarkable mucosal histology
More significant disease
- Intraepithelial eosinophils and lymphocytes
- Basal zone and papillary hyperplasia
Congestion of small vessels with associated microhemorrhage
What is seen here?
Reflux esophagitis
- Hyperemia (redness) in the lower esophagus
What is seen here?
Reflux esophagitis
- Congestion and microhemorrhage
- Basal cell hyperplasia (darker cells)
What is seen here?
What is the clinical presentation of reflux esophagitis?
- Demographic
- Symptoms
- More prevalent in adults > 40 yo
Most common clinical symptoms:
- Dysphagia
- Heartburn
- Regurgitation of gastric contents
More on reflux esophagitis:
- Treatment
- Complications
Treatment:
- Proton pump inhibitors
- H2 histamine receptor antagonists
- Symptomatic relief
Complications:
- Esophageal ulceration
- Hematemesis
- Melena
- Stricture
- Barrett’s esophagus
- Erosive esophagitis is a risk factor for Barrett’s (1-13% annually)
What is Barrett Intestinal Metaplasia?
Premalignant metaplasia caused by gastroesophageal reflux disease (GERD)
- Squamous epithelium -> metaplastic columnar epithelium (still normal morphology, just in the wrong place)
- Common in general population: 1 – 10%
- 12 – 15% of patients with GERD
- Risk of cancer 30 – 125 times greater than age-matched population
- Risk of adenocarcinoma in Barrett: 0.1-0.5% per year
- Periodic endoscopic surveillance
(So reflux esophagitis may -> Barrett’s intestinal metaplasia, may -> adenocarcinoma)
What is seen here?
Goblet cells
What is seen here?
Goblet cells
What is seen here?
Endoscopic lesion in Barrett’s esophagus
Case)
- 63 yo woman
- Progressive dysphagia
- Biopsy of distal esophagus
Adenocarcinoma
What is seen here?
Esophageal squamous epithelium
What is seen here?
- Basal cell hyperplasia
- Intraepithelial lymphocytes
What is seen here?
Adenocarcinoma
- Cells with dark nuclei with different shapes/sizes
- Gland formation
What are diagnostic procedures for:
- Adenocarcinoma
- Reflux esophagitis
Distal esophagus biopsies
Describe esophageal adenocarcinoma
- Incidence
- Etiology
- Predictive factors
- Treatment
- Incidence increased 350% since 1970 (US/Europe)
- Etiology uncertain
- Most cases detected at advanced stage with poor survival
- Preceded by Barrett’s intestinal metaplasia
- Esophagectomy only for either extensive high-grade dysplasia or invasive carcinoma
What is seen here?
Low grade dysplasia in adenocarcinoma
What is seen here?
High grade dysplasia in adenocarcinoma
Describe squamous cell carcinoma
- Incidence
- Demographics
- Symptoms
- Location
- Used to be the #1 type of esophageal cancer (90-95%) in US before 1970
- Mostly African-American men with long hx of smoking and alcohol
- Worldwide: the most common type of esophageal cancer
- Adults >40 yo
- More in men (4x)
- Presentation: dysphagia and weight loss
- Mostly lethal disease
- Half of the cases: middle third of the esophagus
What is seen here?
Mass in esophagus
- This is squamous, but couldn’t tell grossly
What is seen here?
Normal squamous cell epithelium
What is seen here?
Desmoplasia: fibroblast trying to keep tumor from invading??
What is treatment and prognosis for squamous cell carcinoma?
Prognosis: poor
Treatment:
- Esophagectomy
- Photodynamic therapy
What is photodynamic therapy?
- Photosensitizing chromophores, selectively retained by dysplastic malignant tissue
- Light is delivered in the area where the photons are absorbed by the photosensitizer
- Photosensitizer becomes photoexcited and transfers its energy to a chemical substrate that causes biologic damage to the abnormal tissue
