Case 11- Pathology Flashcards
Oesophagitis
Inflammation of the oesophageal mucosa
Causes of Oesophagitis
CRAMPS V
Chemical injury by acidic/alkaline solutions Radiation therapy Alcohol abuse Medications Physical injury Surgery Vomiting
Most important cause is reflux of gastric contents in to the lower oesophagus i.e. GORD
Gastro-oesophageal reflux (GOR)
When the stomach contents move back up the oesophagus. Having GOR once in a while is common
Gastro-oesophageal reflux disease (GORD)
Symptoms or mucosal damage produced by the abdominal reflux of gastric contents into the oesophagus. Often chronic and relapsing. Acid reflux from the stomach.
Symptoms of GORD and Oesophagitis
Regular heartburn, a painful burning sensation in the middle of your chest behind the sternum (breastbone) and in the middle of the abdomen. Taste of food or acid in the back of your mouth.
Common GORD symptoms
Bad breath, nausea, pain in your chest or the upper part of your abdomen, problems swallowing or painful swallowing, respiratory problems and vomiting.
Causes of GORD
RETCH
Resistance= mucosal resistance is reduced, junctional complexes break down and allow acid to enter the mucosa. Reduced bicarbonate
Emptying= decrease in gastric emptying increases the likelihood and frequency of reflux
Tone= Lower oesophageal sphincter tone is reduced, due to pregnancy, obesity and medication
Clearance= oesophageal clearance is reduced, reduction in salivary flow and production. Seen in smokers, the elderly, alcohol
Hernia= loose hiatus muscles in the diaphragm, allows contents from the stomach to enter the oesophagus
Two main symptoms of GORD
Symptoms:
Heartburn- aggravated by fatty/spicy/acidic foods. Most common nocturnally
Acid regurgitation- bitter taste in mouth. Bad breath, nausea, dysphagia, vomiting
Diagnosis of GORD/ oesophagitis
- Clinical- symptoms of heartburn
- Endoscopic- red/congested mucosa
- Manometric- decreased sphincter pressure
- pH- below 4
- Pathological- microscopic evidence of oesophagitis i.e. the presence of acidification and necrotic cells
Complications of GORD
Oesophageal stricture- damage to cells cause scar tissue formation and narrowing of the oesophagus leading to dysphagia
Oesophageal bleeding- can cause ulceration which can haemorrhage
Oesophageal ulcers - where mucosal erosion extends to the submucosa and beyond
Barrett’s Oesophagus
Gastritis
Inflammation of the stomach lining
Gastritis symptoms
Vomiting, bloating, abdominal pain, nausea, burning and anorexia
Gastritis risk factors
Unhealthy food, drug induced (NSAID), H-pylori/ infection, alcohol, spicy food, smoking, reflux
How NSAIDs cause gastritis
NSAIDs inhibit gastroduodenal prostaglandin synthesis, resulting in reduced secretion of mucus and bicarbonate and decreased mucosal blood flow. These factors are normally protective of the mucosa and the balance of mucosal protection/acidic attack can be upset, promoting ulcer formation.
Acute gastritis
Associated with neutrophil infiltration
Surface erosion causing severe mucosal damage
Haemorrhage development
Erosion of the epithelium doesn’t cross the muscularis mucosa, unlike in peptic ulcers
Acute gastritis- aggressive factors and protective factors
Due to an imbalance in aggressive factors and protective factors.
Aggressive factors- increased acid secretion with back diffusion.
Protective factors- decreased production of a bicarbonate buffer. Reduced blood flow and disruption of the adherent mucus layer. Direct damage to the epithelium.
Pathogenesis of acute gastritis
Triggers lead to increase in acid secretion and decrease in protective factors
Decreased bicarbonate production
Direct damage to epithelium
Acute gastritis symptoms
Abdominal pain
Haematemesis
Nausea
Heartburn
Chronic gastritis
Associated with lymphocytes and plasma cells. The presence of chronic mucosal inflammatory changes leading eventually to mucosal atrophy and intestinal metaplasia. Mucosal atrophy is loss of gastric glandular cells. Loss of gastric glandular cells
Intestinal metaplasia = surface, glandular and foveolar epithelia are replaced by intestinal epithelium
Causes of chronic gastritis
- Autoimmune
- Bacterial- H.pylori (90%)
- Chemical- bile and bicarbonate, pyloric bypass operations, gallstones and disorganised motility
- Drugs- Aspirin, NSAID
Symptoms of chronic gastritis
Often asymptomatic. Associated with epigastric pain, nausea and vomiting
Peptic ulcer disease
Tissue necrosis of the mucosa of the alimentary tract (stomach, lower oesophagus or small intestine) which extends through the muscularis mucosa into the submucosa or deeper. It is an open sore in the lining of the stomach and duodenum.
Symptoms of peptic ulcer disease
Vomiting, bloating, abdominal pain, nausea, burning pain in the abdomen and anorexia
Risk factors for peptic ulcer disease
Family history, unhealthy food, drug induced (NSAID), H.Pylori/infection and stress.
Peptic ulcer vs Peptic erosion
Erosion= a defect occurring above the muscularis mucosa, doesnt transverse this layer
Ulcer= breaches through the muscularis mucosa in to the submucosa, can even go deeper to where the blood vessels are. Slower to heal
Acute ulcers and chronic ulcers
Acute ulcers = normally due to severe stress or chemical injury
Chronic ulcers = normally due to H.pylori infection
What causes an ulcer
It results from the loss of balance between the mucosal defence and the acid attack. These normal gastric defence are damaged by exposure to injurious agents. This then leads to destruction and erosion of the mucosa.
Mechanisms of normal gastric defence
- Surface mucus secretion.
- Bicarbonate secretion into the mucus.
- Mucosal blood flow
- Membrane transport within the apical surface
- Epithelial regenerative capacity
- Prostaglandin synthesis
Parts of an ulcer
An ulcer is split into the exudate and necrotic tissue on top, the granulation tissue in the middle and fibrous tissue at the bottom.
Major complications of Peptic ulcers
1) Haemorrhage- may be fatal or cause Iron deficient anaemia
2) Perforation of the GI tract- stomach contents spill into abdominal cavity, leads to acute peritonitis
3) Penetration- ulcer perforates into nearby organs
4) Cancer- Increased risk when H.pylori caused the ulcer
5) Fibrosis- obstructs pylorus, patients will have an hourglass stomach
6) Gastric outlet obstruction — this may result from strictures and stenosis of the pylorus and/or duodenum due to chronic inflammation and scarring.
Gastric ulcer
Pain 1-2 hours after food intake. Presents with Hematemesis (coffee ground blood in vomit), weight loss, equal in both sexes. Melena (sticky dark faeces). Heartburn, chest discomfort and early satiety are commonly seen. Can cause gastric carcinoma. Occurs in the stomach at the lesser curvature and Antrum. Not associated with nocturnal wakening
Duodenal ulcer
Pain 2-5 hours after food intake (relieved by food). There is Melena (digested blood in stool). You get weight gain and night waking. It is more common in males. Occurs in the first part of the duodenum. Heartburn and chest discomfort are less common but can be seen. The pain may keep the patient up at night.
Gastric mucosal protection- diffusion barrier
Lubricates and protects the stomach from its contents.
• Anatomical barrier- resistant epithelium (apical membrane and tight junctions between cells in gastric glands are relatively impermeable to H+).
• Physiological barrier- mucus gel layer and bicarbonate.
Features that warrant a gastroenterology referral
- Bleeding or anemia
- Early satiety
- Unexplained weight loss
- Progressive dysphagia or odynophagia
- Recurrent vomiting
- Family history of gastrointestinal cancer
Barrett’s Oesophagus
A pre-cancerous state caused by long-standing GORD. Can progress to adenocarcinoma
Chronic damage due to acid exposure as a result of the malfunction of the lower oesophageal sphincter. Promotes inflammatory response
Ultimately leading to epithelial necrosis
Believed to promote metaplasia of the stratified squamous epithelia to simple columnar epithelia
Progression of Barrett’s Oesophagus
Normal oesophageal epithelium –> Barrett oesophagus –> Dysplastic Barrett oesophagus –> Oesophageal adenocarcinoma
Diagnosing Barrett’s Oesophagus
Barrett’s oesophagus on a OGD (Esophagogastroduodenoscopy) in combination with histological changes. Instead of the oesophagus being lined with normal stratified squamous cells it is lined by simple columnar epithelium with interspersed goblet cells. There will also be increased immune cells.
Mechanism of action of cancer formation in the Oesophagus
1) Normal stratified squamous epithelium lining of the oesophagus.
2) There is exposure to causative risk factors leading to metaplasia. This is the replacement of normal stratified squamous epithelium lining of the oesophagus with simple columnar epithelium with or without goblet cells.
3) Further dysplasia- abnormal cell growth and cell differentiation
4) Transformation and oesophageal Adenocarcinoma formation (oesophageal cancer).
5) Adenocarcinoma local invasion and secondary site metastasis (spread)
Upper GI neoplasm
- Squamous cell carcinomas- usually upper or mid oesophagus. Often detected when malignant, so have reached the basement membrane.
- Adenocarcinomas- lower oesophagus, stomach and small intestine. The stomach is glandular in structure hence why there is a lot of adenocarcinomas. Often detected when malignant, so have reached the basement membrane.
- Rare- gastrointestinal stromal tumours (GIST) and Lymphoma (lymphocytes change and grow out of control)
When to consider an OGD endoscopy
DOC ALARM • Dysphagia (difficulty swallowing) • Odynophagia (pain swallowing) • Choking • Anaemia • Loss of weight • Age (over 55) • Recent onset or progressive symptoms • Melaena / haematemesis
Risk factors for upper GI neoplasms
Smoking, alcohol, Barrett’s Oesophagus, Asbestos
Oesophageal cancer
Most Oesophageal cancers are malignant, fewer then 1% are benign
Oesophagus- Squamous cell carcinoma
90% of oesophageal cancer worldwide. Squamous cells line the oesophagus. Tend to be found in the upper and middle oesophagus
Oesophagus- Adenocarcinomas
Arises from the superficial and deep glands of the oesophagus, mainly in the lower third of the oesophagus, especially near the gastroesophageal junction. Is a progression of Barrett’s Oesophagus.
Epidemiology Oesophageal cancer
The rate is three times higher in men than women. The highest rate are found within the Middle East, South Africa, northern China, southern Russia and India. More likely to get it when older.
Risk factors for Oesophageal cancer
Alcohol Smoking Poor diet Genetics e.g. peutz-jeghers syndrome Predisposing conditions e.g. Barretts Oesophagus, diverticula
Symptoms of Oesophageal cancer
- Dysphagia- difficulty swallowing
- Odynophagia- pain when swallowing
- Weight loss
- Acid reflux / substernal heart burn
- Dyspnoea, cough, hoarseness and pain in the retro-sternal, back or right upper abdomen.
Types of Gastric Neoplasia
- Adenocarcinomas- more then 90% of stomach cancers develop in the cells of the glandular stomach lining. Derived from columnar glandular epithelium cells.
- Gastric lymphoma and MALToma- develop in the lymphatic tissue which is beneath the epithelium.
- Gastrointestinal stromal tumours (GISTs)- develop in the muscle or connective tissue of the stomach wall.
Aetiology of Gastric cancer
Genetic factors- pernicious anaemia, family history, BRCA 1/2 mutation, type A blood
Precursor lesions- Mentrier’s disease, dysplasia, chronic strophic gastritis
Environmental factors- H.pylori, low vit A and C, smoking, radiation exposure, poor drinking water
Clinical presentation of gastric cancer
Weight loss Abdominal pain Anaemia Dysphagia Nausea and vomiting Bloating and indigestion
Where in the stomach do gastric cancers arise
They mostly arise in the antrum (50%), the gastric body (30%), the fundus or cardia (20%).
Diffuse gastric adenocarcinoma
The tumour consists of discohesive cells i.e. loose intracellular connection infiltrating through all the layers of the stomach wall. It is accompanied by extensive fibrosis and inflammation. Many tumour cells have large intracytoplasmic vacuoles that push the nucleus to the peripheries creating a signet ring appearance. No know precursor for diffuse type. Discohesive cells dont express E-cadherin which connects cells together
Intestinal gastric carcinoma
A type of adenocarcinoma of the stomach showing papillary growth patterns. Intestinal type tumours follows a step wise progression from chronic gastritis to intestinal metaplasia, dysplasia, carcinoma in situ and invasive carcinoma.
