Esophagitis + Esophageal Cancer Flashcards
What are 3 causes of esophagitis?
Erosive esophagitis
Eosinophillic esophagitis
Infectious esophagitis
What are the different types of erosive esophagitis? How can they be characterized? How can they be caused? What are some symptoms?
Chemical and pill esophagitis
Reflux esophagitis
(erosive)
Endogenous:
acid in reflux
Exogenous:
lye, acids, or
detergent
pill
Strong or mild
Acute or chronic
Necrosis? ulcer?erosion?inflammation
Barrett?s (premalignant)
What are some symptoms of iron pill esophagitis? Pill esophagitis in general? What else can cause pill esophagitis? Where does it usually occur? How is it treated?
Iron pill (ferrous-sulfate)
Ulcertation
Acute inflammation
Pigmented material, blue on Perls? stain
Chest pain, pain with swallowing, acute
heartburn
NSAID
antibiotics
Usually mid esophagus/aor tic arch Transition zone between skeletal/smoot h muscle
Avoid offending agent
Symptom control
Acid reflux prevention (no clear data)
Behavioral changes - drink 8 oz water with
pill, stay upright for 30 minutes, look for
alternative drugs
What are the cells like that are characteristic of herpes esophagitis? Where are they seen? How are they differentiated from CMV cells? What are the ulcers like? When does HSV infectious esophagitis occur? What are the symptoms? What is the path. like? Where should a biopsy be taken? What will be seen? What is the treatment? What are the ulcers like in CMV infectious esoph.? What are the cells like? How should it be treated?
Cells are:
Margination
Molding
Multinucleation
They are seen at the edge of the ulcers not in the ulcer
They ulcers are punched out.
Immunocompromised (solid organ transplant or
BMT) or immunocompetent
Odynophagia, dysphagia, chest pain, fever
Vesicles, small ulcers, ?volcano like?
Biopsy from edge of ulcer
Multi-nucleated giant cells, ground glass nuclei,
eosinophilic inclusions (Cowdry type A
inclusion bodies)
Treatment: Acyclovir, famcyclovir, valcyclovir
CMV cells have:
Cytoplasmic and nuclear inclusions
Ulcers linear and deeper, larger
Intranuclear inclusion bodies
Rx: ganciclovir (IV), foscarnet (IV)
Switch to valganciclovir
3-6 weeks
Eye exam to evaluate for retinopathy
In which patients does infectious esophagitis occur? What is the most common bug? What are the symptoms? How is this most common cause diagnosed? What is often coexistent with? How is it treated? What is seen grossly? Microscopically?
Immunosuppression
Use of inhaled corticosteroids
Candida most common in immunocompetent and
immunocompromised
Odynophagia or dysphagia
Brushings KOH/PAS stain
Oral thrush coexistent in 2/3
Trial of empiric fluconazole
Requires systemic therapy
Grossly: white plaques
Tissue invasive pseudohyphae and budding yeast
forms
What is the pathology of eosinophilic esophagitis compared to reflux esophagitis? How else does it differ from reflux esophagitis? What is it associated with? What is the treatment? What can be seen on endoscopy? What is this due to? What patients might have eosinophilic esophagitis? What will they have a history of? Symptoms? What will be found on lab tests, endoscopy, and barium swallow? What must be excluded? How? How is it treated?
Larger numbers of intraepithelial eosinophils and
more superficially located than reflux esophagitis
Absence of acid reflux and failure of PPI
Atopic: atopic dermatitis, allergic rhinitis, asthma or
peripheral eosinophilia
Treatment: dietary restriction, corticosteroids
Furrows—>Dysphasia Rings—>Food impaction
Initially disease of children but more
common now in adults
Young men
History of atopy (allergies, asthma,
hayfever)
Symptoms: dysphagia, food impaction,
heartburn
Lab tests: elevated IgE, peripheral
eosinophilia
Barium swallow-small caliber, focal or long
tapered strictures, concentric rings
EGD-ringed esophagus, linear furrows,
eosinophilic abscesses, strictures (1/3
normal esophagus)-Biopsies: >15 eos/HPF
Must exclude GERD (Trial of PPI)
Trial of PPI Topical or systemic corticosteroids Dietary changes (wheat, soy, egg, dairy, shellfish, peanuts) Allergy referral Cautious dilation
What is the most common cause of esophagitis? What are some risk factors? What % of population? Define it? Symptoms? Complications? What is the path.? What are the symptoms? What is the treatment? Describe reflux esophagitis grossly. Microscopically?
Definition: Inflammation of the lower esophagus, resulting from damage caused by acid reflux from the stomach
Most common cause of esophagitis, 10% of
population
B. Risk factors include alcohol, tobacco, obesity, fat-rich diet, caffeine, and hiatal hernia
Heartburn and regurgitation
Complications: severe ulcerations,
strictures, Barrett?s esophagus, and
adenocarcinoma
Reflux of gastric contents into the
esophagus
Hyperemia, eosinophils/neutrophils on
pathology
Clinical symptoms: dysphagia, heartburn,
epigastric pain, reflux, asymptomatic
Treatment: Acid suppression, behavioral
modifications
GROSSLY:
Reddish, hyperhemic areas at
the squamocolumnar junction
Erosions, or ulcers followed
by strictures
Barrett?s esophagus (salmon-
colored mucosal tongues) in
long-standing cases
MICROSCOPICALLY:
Basal cell hyperplasia
>20% (nl
Define Barrett’s esophagus Why is it important? What causes barretts esoph. ? Why is it serious? What are some treatments? What is the main difference between low grade dysplasia and high grade dysplasia? Why is that important?
Definition
intestinal metaplasia within the esophageal squamous mucosa.
Is a
consequence
of GERD
Why important?
Precursor for
cancer
Replacement of normal squamous epithelium with
specialized columnar epithelium (?intestinal-like?)
resulting from epithelial injury (esophagitis) and
healing/repair in an acid environment
Found in 2%-20% of GERD Patients
Increased risk for esophageal adenocarcinoma
Chemoprevention
NSAIDs/Aspirin/Statins
Antisecretory therapy
Acid suppression
Ablative therapies
Thermal (Radiofrequency ablation)
Mechanical (Endoscopic mucosal resection,
Endoscopic submucosal dissection,surgical)
Photodynamic therapy, Cryotherapy
LGD: Architecture still maintained
HGD: Architecture lost somewhat
Important for prognosis.
What are some malignant neoplasms that occur in the esophagus? Benign? To which LNs do malignant neoplasms metastasize ?
Squamous Cell CA
Adenocarcinoma
Leiomyoma
fibrovascular polyp of esophagus
Squamous papilloma
o Upper 1/3 – cervical lymph nodes
o Middle 1/3 – mediastinal, paratracheal, and tracheobronchial nodes
o Lower 1/3 – gastric and celiac nodes.
Why is the TNM staging different in the colon compared to elsewhere in the GI system? What is the T staging like for neoplasms in the GI system? In the colon?
Colon is unique in that it lacks rich lymphatics in the mucosa as compared to other portions of the gut
** Mucosal adenocarcinoma in colon virtually has no risk
for lymphatic invasion and metastasis. It is therefore
regarded as carcinoma in situ when staging.
Tumor Invasion of lamina propria:
Colon: Tis
Elsewhere: T1a
Invasion of submucosa
Colon:T1
Elsewhere:T1b
Invasion of muscularis propria: T2
Serosa: T3
Through Serosa: T4
What are some risk factors for esophageal cancer? What are the symptoms?
IRRITATION:
Alcohol
Barrett?s esophagus
Cigarettes
Dietary (Very Hot Tea)
Esophageal Diseases (Plummer Vinson syndrome, achalasia, esophagitis)
Familial
11, Esophageal carcinoma presents late (poor prognosis).
1 . Symptoms include progressive dysphagia (solids to liquids), weight loss, pain, and hematemesis.
2. Squamous cell carcinoma may additionally present with hoarse voice (recurrent laryngeal nerve involvement) and cough (tracheal involvement)
What is squamous cell CA like grossly? Where in the esophagus is it located? Microscopically?
Gross-Middle 1/3 in 50% of cases
Polypoid or exophytic mass with
gray-white cut surface
Can be ulcerated or diffusely infiltrative that spread within the esophageal wall causing thickening, rigidity, and luminal narrowing.
Local extension into respiratory tree, aorta, medistinum, and pericardium can occur
Microscopic:
Nests of malignant cells that partially
recapitulate the organization of squamous
epithelium
What is Adenocarcinoma like grossly? Where is it located in the esoph? Microscopically? What is it like if its developed due to barretts?
Gross:
Flat or raised
Ulcerated or
infiltrative
Lower 1/3
MICROSCOPIC:
Malignant tumors
forming glandular
structures
Mucin producing
BARRETS ADENOCARCINOMA:
large exophytic
tumor fills distal
esophagus
Barrett?s epithelium
is tan mucosa above
and to one side of
tumor
Describe leiomyoma.
leiomyoma are the most common
benign tumors of esophagus
5 cm lobulated
leiomyoma has bulging,
white, whorled cut
surface
Submucosal leiomyoma
circumscribed
composed of intersecting
fascicles of bland spindle cells
with abundant cytoplasm
What is a fibrovascular polyp of esophagus? Where is it located? What is it like grossly and microscopically? What are the complications?
A 7.0-cm polyp lies posterior to the larynx and extends from the cervical esophagus causing asphyxiation
squamous epithelial lining
core of mature fibromyxoid
tissue with scattered thin-walled
blood vessels and variable
adipose tissue
