Esophagus Path

Question 1

What is different about the esophagus than the rest of the gut?

Answer 1

no serosa to help limit spread of tears/rips and cancer

Question 2

What kinds of muscle is the esophagus made of?

Answer 2

upper - mostly skeletal
middle - skeletal and smooth
distal - mostly smooth

Question 3

What are the four layers of the wall of the esophagus?

Answer 3

mucosa - squamous epithelial lining and lamina propria, bordered by muscularis mucosa
submucosa - glands
muscularis propria
adventitia

Question 4

What changes at the gastro-esophageal junction and how is it seen grossly?

Answer 4

squamous lining of esophagus meets glandular of stomach

white/pale tan changes to pink

Question 5

What are the symptoms of esophageal varices?

Answer 5

none unless they bleed - then light headedness, pale, hematemesis, black tarry stools

Question 6

Other than esophageal varices, what are other causes of upper GI bleeding?

Answer 6

gastric and duodenal ulcers
Mallory-Weiss tears
less common - gastric tumors, severe GERD, vascular ectasias

Question 7

What can cause esophagitis?

Answer 7

infections (CMV, Candida)
irritant or corrosive substances
prolonged gastric intubation
XRT or chemo
GERD - most common
allergy (eosinophilic)

Question 8

What are the symptoms of eosinophilic esophagitis?

Answer 8

dysphagia - most common
recurrent food impactions
heartburn
maybe hx of atopy

Question 9

What is the mechanism of eosinophilic esophagitis proposed to be?

Answer 9

corrugated esophagus with concentric mucosal rings found

histamine release from sensitized mast cells - Ach release and contraction of muscularis mucosa

Question 10

What is seen on endoscopic exam of eosinophilic esophagitis?

Answer 10

narrow lumen
circular ridges and longitudinal furrows
dilation of strictures –> tears in mucosa

Question 11

What are the microscopic features of eosinophilic esophagitis?

Answer 11

top heavy distribution of eosinophils

Question 12

What are possible symptoms of reflux esophagitis?

Answer 12

odynophagia and dysphagia
chest pain 
erosions and ulcerations of squamous mucosa --> metaplasia = Barrett 
nausea after eating
stomach fullness or bloating

Question 13

What causes GERD?

Answer 13

mechanical problems with LES
excess acid/pepsin/bile
slowed gastric clearance
ingestion of irritating substances (smoke, meds)
decreased efficacy of anti-reflux mechanism
ineffective peristalsis

Question 14

What is medical therapy for reflux esophagitis?

Answer 14

PPIs

surgery to tighten LES

Question 15

What is the criteria for a pathologist to diagnose reflux esophagitis?

Answer 15

eosinophils, possible neutrophils, in epithelium (not top heavy distribution like EE)
basal zone hyperplasia (>20% of wall)
papillae elongation (more than 2/3 way up epithelium)

Question 16

What are the potential consequences of severe reflux esophagitis?

Answer 16

fibrosis of esophagus
dysphagia, odynophagia, heartburn and/or slow GI bleeding leading to iron def
barrett

Question 17

What is Barrett esophagus?

Answer 17

replacement of squamous epithelium of distal esophagus with intestinal columnar epithelium, presence of any goblet cells

Question 18

What does Barrett esophagus put you at risk for?

Answer 18

esophageal adenocarcinoma - esp among men with long term reflux who smoke and drink

Question 19

What are the two types of esophageal cancer and where in the esophagus do they occur?

Answer 19

squamous cell - upper 2/3

adenocarcinoma - lower 1/3

Question 20

Which esophageal cancers are increasing and decreasing in prevalence?

Answer 20

SCC decreasing (smoking and alcohol decreasing) - black males
adenocarcinoma increasing (reflux) - white males >50!

Question 21

What are symptoms of esophageal cancer?

Answer 21

dysphagia, odynophagia, weight loss, chest pain radiating to back, hoarseness, coughing, hematemesis, increased risk of aspiration pneumonia

Question 22

Why is esophageal cancer often not diagnosed until late stage?

Answer 22

no symptoms til half of lumen is obstructed - already big tumor

Question 23

What is the microscopic appearance of adenocarcinomas?

Answer 23

arise in glandular epithelium - lumens, cribiforming, papillary growth, mucin production, cohesive cell nests/balls, signet ring forms

Question 24

Where do SCCs arise?

Answer 24

arise in squamous epithelium - native (skin, esophagus, mouth) or metaplastic (endocervix, bronchi)

Question 25

What are the microscopic features of SCC?

Answer 25

disordered cell arrangement, hyperchromasia, high N:C ratio, apoptotic figures, keratin, keratin pearls, desmosomes

Question 26

What is the most important prognostic indicator in esophageal cancer?

Answer 26

STAGE

Question 27

What is the basic survival rate for esophageal cancer?

Answer 27

15%

most pts die w/i 1 yr of diagnosis

Question 28

What are curative treatments for esophageal cancer?

Answer 28

if EARLY - endoscopic mucosal resection, surgical resection, radiation with chemo

Question 29

What are palliative treatments for esophageal cancer??

Answer 29

stent to keep lumen open, feeding gastrostomy, tumor ablation, radiotherapy

Question 30

What are the T designations for esophageal cancer?

Answer 30

T1 - tumor no deeper than submucosa (not seen)
T2 - tumor invades into muscularis propria
T3 - tumor invades adventitia
T4 - tumor invades adjacent structures/organs