135b/137b - Pathology and Clinical Features of Esophageal Disorders Flashcards
List the histological changes seen in chronic GERD (4)
- Basal cell hyperplasia
-
Extension of vascular papillae to the top 1/2
- Due to vascular congestion
-
Inflammaotry infiltrate
- Eosinophils, lymphocytes, few neutrophils
- Ballooning of squamous cells
What defines Barrett’s Esophagus
Columnar metaplasia of the esophageal mucosa that contains intestinal metaplasia
- The esophagus is only supposed to have stratified squamous epithelium
- In Barrett’s it will contain columnar cells (columnar metaplasia) and goblet cells (intestinal metaplasia)
- Intestinal metaplasia is specifially goblet cells
What abnormality is pictured here, at the gastroesophageal junction?
What cell types would histology show?
Barrett’s esophagus
- Esophagus should be white-ish all the way until the GEJ
- White = non-keratinous stratified squamous cells
-
The pinkish stomach cells should not be present here
- These are nonciliated simple columnar cells
(gastric metaplasia) - May also contain goblet cells (intestinal metaplasia)
- These are nonciliated simple columnar cells
Which infectious esophagitis will appear with punched out ulcers?
What is the treatment?
HSV1 or HSV2
Self limited; acyclovir, valacyclovir if needed
List 3 potential complications of GERD
- Erosion/ulceration
- Strictures
- Secondary to fibrosis from ulceration
- Barrett’s esophagus
How is GERD treated?
-
Lifestyle modification = mainstay
- Smaller meals, don’t eat before bed
- Weight reduction
- Pharmoacotherapy
- Decrease acid secretion w/ H2 blocker or PP1
- Surgery is a last resort
Which parts of the esophagus are affected by GERD?
Which parts are affected by eosinophilic esophagitis?
GERD - distal
EoE - Proximal and distal
Describe the pathogenesis of Barrett’s esophagus
- Chronic GERD
- -> Inflammation, ulceration of esophageal squamous mucosa
- -> Columnar/mucinous metaplasia; mucus is protective
- This can lead to intestinal metaplasia (goblet cells)
- May develop into adenocarcinoma
What is the difference between metaplasia and dysplasia?
-
Metaplasia = transformation of one cell type into another
- Ex: Stratified squamous -> columnar in Barrett’s esophagus
- However, the new columnar cells look pretty normal
-
Dysplasia = cells are ~weird~
- Non-uniform shape, crowded, nuclear changes
- May be accumulating mutations that could be pre-cancerous
- High-grade dysplasia = carcinoma in situ
Which esophageal pathology is most strongly linked to food-antigens?
Eosinophilic esophagitis
What is the histologic hallmark of squamous cell carcinoma?
Keratin formation
Will also see:
- Nucelar hyperchromasia
- Pleomorphism (cells are not uniform)
- Increased nucleus:cytoplasm ratio
What esophageal abnormaility is pictured?
What complications may result?
Sliding hiatal hernia
(Herniation of stomach into the mediastinum through the esophageal hiatus of the diaphragm)
Predisposes to acid reflux
List 4 endoscopic findings of eosinophilic esophagitis
- Linear furrows
- Rings
- Strictures
- White patches/plaques
What kind of epithelium is this?
Where might it be found?
Non-keratinized stratified squamous epithelium
Found in places exposed to the external environment
(Esophagus, external anal canal)
List 3 histologic findings of eosinophilic esophagitis
-
Eosinophils: 15+ in 2+ high power fields, or 25+ in any one field
- Remeber, eosinophils are pink on H&E
- Basal cell hyperplasia
- Fibrosis in the lamina propria
Eosinophils and fibrosis differentiate EoE from GERD
What is the difference between high-grade dysplasia and adenocarcinoma?
Becomes adenocarcinoma when the dysplastic cells breach the muscularis mucosa
No difference in what the cells look like
Barrett’s esophagus is a risk factor for which type of cancer?
Esophageal adenocarcinoma
(Squamous cell carcinoma arises from squamous cells; in Barrett’s esophagous, the cells are no longer squamous)
Where does Zenker’s diverticulum usually occur?
What are the symptoms? (5)
Between transverse fibers of the cricoharyngeus and oblique fibers of the lower inferior constrictor
- Aspiration
- Halitosis
- Regurgitation
- Gurgling in throat
- Neck fullness
Which infectious esophagitis will appear with white plaques that are easily scraped off?
What is the treatment?
Candidal esophagitis (candida albicans)
Treat with fluconazole
What is the most common cause of GERD?
Transient relaxation of the lower esophageal sphincter
This causes 90% of reflux
Which infectious esophagitis will appear with linear/serpiginous ulcers?
What is the treatment?
CMV esophagitis
Treat with ganciclovir
(Usually in immunocompromised patients)
Which medications are most commonly implicated in pill esophagitis?
How is it treated?
- Bisphosphonates
- Alprenolol
- Doxycycline/Tetracycline
- Quinidine
- Potassium
- Iron
- Pinaverium
- Emepronium
BAD Q PIPE
Stop offending medication, give PPI and Carafate
What esophageal pathology is shown here?
What cells are we likely to see on histology?
Eosinophilic esophagitis
- Rings and linear furrows are specific for EoE
- Histology
-
Eosinophils (>15 in 2 hpfs or >25 in 1 hpf = diagnostic)
- May also be in microabscesses
- Hyperplasia
- Fibrosis
-
Eosinophils (>15 in 2 hpfs or >25 in 1 hpf = diagnostic)
What esophageal abnormality is shown?
Paraesophageal hernia
How is eosinophilic esophagitis treated?
- Medicine
- PPI
- Swallowed topical steroids
- Biologics (immune modulators)
- Diet
- Directed by allergy testing or elimination diet
- Endoscopic therapy
- Dilation helps open up rings/scar tissue
What is the most important prognostic factor for esophageal cancer?
Stage; based on depth of invasion
