CPC: Pathology of the Esophagus

Question 1

Answer 1

normal tissue of the esophagus

Question 2

what is the normal epithelium of the esophagus

Answer 2

squamous eptihelium (stratified)

Columnar cells are more resistant to acid and pepsin and the metaplasia may be a defense against refluxed acid. In Barrett’s, the cells are usually of a type referred to as specialized columnar epithelium (a distinctive type of intestinal metaplasia). They include mucus cells, and have a tendency to resemble cells found in the small intestine.

Squamous epithelium, seen in the esophagus and skin, consists of layers of flat cells. Columnar epithelium, characteristic of the rest of the gut, consists of a single layer of tall, rectangular cells. In Barrett’s esophagus, the normally squamous epithelium of the lower esophagus becomes replaced with various types of columnar cells, that may predispose to a type of cancer known as adenocarcinoma.

Question 3

Answer 3

stratified squamous epithelium non-keritinized

Question 4

Answer 4

normal stomach– see all the ducts

Question 5

what cells of the stomach?

Answer 5

mucous cells– see goblets

Question 6

what part of the GI?

Answer 6

small intestine– tons of villi and microvilli have a brush boarder

Question 7

what cells of the GI?

Answer 7

large intestine. less villous and more gladular.

Question 8

what part of the GI?

Answer 8

appendix–see the galt– lymphoid tissue.

Question 9

T/F anal epithelial looks the same as esophageal

Answer 9

true. they are both stratified squamous non-keratinized epithelium.

Question 10

barretts esophagus involves the change from normal ____ epithelium in the esophagus to ____.

Answer 10

squamous to cuboidal. can become a carcinoma.

Question 11

a person suffering from severe heart burn that is now affecting his ability to swallow had a biopsy and esophagus is found to look like this. what is going on?

Answer 11

neoplasia– change into cuboidal. there are also more ducts and goblet cells. cuboidal cells are more ersistant to acid and can secrete their own mucus.

Columnar cells are more resistant to acid and pepsin and the metaplasia may be a defense against refluxed acid. In Barrett’s, the cells are usually of a type referred to as specialized columnar epithelium (a distinctive type of intestinal metaplasia). They include mucus cells, and have a tendency to resemble cells found in the small intestine.

Squamous epithelium, seen in the esophagus and skin, consists of layers of flat cells. Columnar epithelium, characteristic of the rest of the gut, consists of a single layer of tall, rectangular cells. In Barrett’s esophagus, the normally squamous epithelium of the lower esophagus becomes replaced with various types of columnar cells, that may predispose to a type of cancer known as adenocarcinoma.

Question 12

note the pathophysiological concepts of carcinoma:

– Metaplasia in response to chronic inflammation
• Esophagitis  Barrett Esophagus

– Inflammation-dysplasia-carcinoma sequence
• Inflammatory Bowel Disease  Dysplasia  Colonic
Adenocarcinoma

– Polyp-cancer sequence
• Colon adenoma  Colonic adenocarcinoma

Question 14

what is metaplasia

Answer 14

the reversible change in which one differentiated cell type (epithelial or mesenchymal) is replaced by another cell type. usually in response to injury. in the esophagus, chronic GERD can results in squamous epithelium being replaced with cuboidal because it’s better with dealing with acid.

Question 15

4 broad causes of ESOPHAGITIS

Answer 15

1. Chemical (Gerd, pills/medication without sufficient fluids, irradiation, caustic/corrosice/acidicc material)
2. infectious (CMV, Herpes, EBV, fungal like candida)
3. graft vs host
4. immunoallergic (eosinophilic esophagitis)

Question 16

Answer 16

esophagitis

Gross: Hyperemia (redness) +/- ulceration (loss of epithelium) Location: ex. GERD - lower; Infectious - anywhere Severity: Ulceration more common with more severe injury

Question 17

what white cells might you see in someone with esophagitis

Answer 17

neuotrophils, eosinophils.

might see basal cell apoptosis, atrophy and fibrosis

• if it’s due to an infectious cause, you might see ulceration adn the cause of the infectious agent (like hyphae of the fungal infection)

Question 18

which part of the esophageal epithelum is normal?

Answer 18

Question 19

Answer 19

herpes esophagitis

Question 20

a person with CMV esophagitis will most likely have ___ chromatin and ulceration with reactive ___ eotihelium. inclusions on the tissue will show ___ ____ ___

Answer 20

a person with CMV esophagitis will most likely have SMUDGED chromatin and ulceration with reactive SQUAMOUS eotihelium. inclusions on the tissue will show VIRAL CYTOPATHIC EFFECTS

Question 21

risk factors fo GERD

Answer 21

obesity, pregnancy, alcohol and tobacco use, hernia, delayed gastric emptying can decrease the function of LES and allow acid to affect the esophagus.

Question 22

outline what is going on with these 3 biopsies of different esophagus’s

Answer 22

1. normal
2. GERD– there is more metaplasia– mild basal zone expansion in yellow area and. abnormal squamous maturation, with som e intrapeithelial inflammatory cells (occasional eosinophils, more lymphocytes)
3. eosinophilic esophagitis (inflammation and way more eosinophils)

Question 23

treatment of GERD

Answer 23

PPIs, H2 receptor antagonists, lifestyle changes.

watch for stricture, progrssion to barrets esophagus through metaplasia, bleeding etc.

Question 24

what demographic is affected more by eosinophilic esophagitis?

Answer 24

children–usually young men like teenagers. it is now being recognized in younger adults.

Question 25

where does eosinophilic esophagitis fit into the dysphagia scheme? (draw out dysphagia scheme)

Answer 25

• mechanical– solids only. intermittent.

Question 27

a young man has been concerned that it is harder and harder to get his dinners “all the way down.”

upon examoination you also notice eczema, asthma, and allergic rhinitis.

What do you expect his endoscope features to look like?

Answer 27

esophageal rings and trachealization.

biopsies should find lots of inflammatory white cells like eosinophils.

Question 28

treatment for eosinophilic esophagitis

Answer 28

PPI, swallowed steroids, dietary elimination.

Question 29

in barretts esophagus, ____ epithelium of distal esophagus is replaced by intestinal type ____ epithelium (with ____ cells), as a consequence of chronic reflux ___

Answer 29

Squamous epithelium of distal esophagus is replaced by intestinal type columnar epithelium (with Goblet cells), as a consequence of chronic reflux esophagitis

Question 30

what gross features would you expect to see in someone who’s metaplasia is become barrett’s esophagus?

Answer 30

Endoscopy: tongues of red, velvety mucosa extending from gastroesophageal junction into squamous mucosa

Question 31

someone with recurrent GERD was biopsied and this was seen. outline the histological features in this image.

Answer 31

there are goblet and columnar cells in the esophagus (should just be squamous)

Question 32

having barretts esophagus follows the ___ ____-____ pattern of carcionma, and increases the risk of ____ ____.

Answer 32

having barretts esophagus follows the CHRONIC INFLAMMATION-METAPLASIA pattern of carcionma, and increases the risk of ESOPHAGEAL ADENOCARCINOMA.

– Barrett Esophagus can develop dysplasia, considered premalignant
(0.2-2.0%/year)
• Risk of cancer progression: low grade (0.7%) or high grade (6%) depending on
how close to cancer it looks like (more later on dysplasia) • Endoscopic surveillance is required

Question 33

Answer 33

Adenocarcinoma
• Previous diagnosis of Barrett esophagus with
dysplasia, lost to follow up

• Large exophytic/polypoid mass at the GE
junction – consistent with adenocarcinoma

Question 34