Esophagus Pathology Flashcards
Vascular diseases
- esophageal varices
Infectious/inflammatory diseases
- achalasia, chemical esophagitis, infectious esophagitis, reflux esophagitis
Traumatic diseases
- mallory-weiss syndrome
Anatomic diseases (congenital/acquired)
C: atresia, diverticula, fistula, hiatal hernia, rings, stenosis, webs
A: diverticula, fistula, hiatal hernia, rings, stenosis, webs
Idiopathic diseases
- achalasia
Neoplastic diseases
- adenocarcinoma, barrett’s esophagus, benign tumors, squamous cell carcinoma
Squamocoloumnar junction (SCJ)
Z line
Anatomic gastroesophageal juction (GEJ)
defined as takeoff of gastric fold
Relation of SCJ to GEJ
- normally SCJ approximates GEJ
Anatomic disease: atresia & fistula
- congenital
- choking, coughing, cyanosis w/ feeding
- amenable to surgical correction
Anatomic disease: achalasia
- failure of LES to relax: narrow distal segment, dilated proximal segment
- progressive destruction of myenteric plexus
- dysphagia
- increased risk of carcinoma
Achalasia: primary vs. secondary
- primary: idiopathic
- secondary: Chagas disease, scleroderma
Anatomic disease: hiatal hernia
- protrusion of stomach above diaphragm
- idiopathic and asymptomatic
- two types: sliding (95%), paraesophageal (rolling-5%)
- *PE hernia patients at risk for strangulation (infarction of incarcerated hernia)**
Anatomic diseases: diverticula-types
- congenital vs. ACQUIRED
- true (contain all gut layers) vs. FALSE
- PULSION (peristalsis against a closed sphincter) vs. traction (extrinsic pull, secondary to inflammation)
Zenker diverticula
- pulsion, from above UES
Mid esophageal diverticula
traction
Epiphrenic diverticula
- pulsion, from above LES
Mallory-Weiss syndrome
- hematemesis from lacerations of GEJ mucosa/submucosa
- caused by forceful retching/coughing/vomiting
- alcoholics, persons with eating disorders
Esophageal varices causes
- consequence of portal hypertension
Stenosis, Webs, Rings
Web: shelf of tissue, congenital, post inflammation
Ring: circumfrential, example-Schatzki @ SCJ
Chemical and pill esophagitis cause
- topical injury due to ingestion of alcohol, corrosive substances (acid,lye), hot liquids
- cytotoxic chemotherapy (radiation, GVHD)
- “stuck” pills: doxycycline (acne), aspirin, iron, alendronate
Kissing ulcers
- ulcers facing each other
- seen with doxycycline
Infectious esophagitis: who gets it, presentation
- seen in immunocompromised
- ODYNOPHAGIA
Infectious esophagitis: causes & presentation
- candida: white plaques
- herpes: numerous punched out ulcers (3 Ms: multinucleation, margination, molding)
- cytomegalovirus: single deep ulcer, “owl’s eye”
GERD vs. reflux esophagitis (RE)
- GERD: condition that develops when reflux of stomach contents causes troublesome symptoms and or complications
- RE: endoscopic or histologic evidence of reflux associated injury
GERD: prevalence, pathophysiology, symptoms
- 10-20% in West,
GERD: diagnosis, treatment, complications
- diagnosis: clinical, further testing if not responding to treatment
- treatment: antacids, anti secretory (PPIs), surgical (nissen fundoplication)
- complications: stricture, barrett’s esophagus, adenocarcinoma
Types of GERD
- erosive: mucosal break (40%)
- non erosive (60%)
Histologic features of reflux
- epithelial hyperplasia: basal zone hyperplasia, papillary elongation
- dilated intercellular spaces
- intraepithelial eosinophils
Epithelial hyperplasia
- compare height of papillaries and basal zone to entire squamous layer
- normal: PE=50%, BZH=13%
- abnormal: PE=84%, BZH=34%
Pathogenesis of heartburn in GERD
- erosive: mucosal breaks allow acid to get through
- non erosive: dilated intercellular spaces allow acid to get through
Eosinophilic esophagitis: definition
- clinicopathologic disorder
- > 15 intraepithelial eosinophils per high power field
- absence of pathologic GERD: normal pH, lack of response to high dose PPI medication
Eosinophilic esophagitis: frequency, symptoms
- frequency: increasingly recognized; 2-27/100,000 over 16 year period
- symptoms include FOOD IMPACTION, dysphagia (adults), GERD, feeding intolerance (children)
Eosinophilic esophagitis: diagnosis, treatment, complications
- esophageal symptoms + mucosal biopsy + exclusion of GERD (lack of response to PPI or normal pH monitoring)
- treatment: elimination and elemental diets, acid suppression, TOPICAL CORTICOSTEROIDS, dilatation of strictures
- complications: stricture
Endoscopy signs of eosinophilic esophagitis
- trachealization, linear furrowing
Histologic features of EoE
- > 15 eos/HPF
- eosinophilic MICROABSCESSES, SUPERFICIAL LAYERING, BZH, DIS
Barrett’s Esophagus: definition
- endoscopically evident apparent columnar mucosa proximal to GEJ
- biopsy demonstrating intestinal metaplasia (GOBLET CELLS)
Barrett’s esophagus: prevalence, etiopathogenesis, symptoms
- 10% of w/ symptomatic chronic GERD, many asymptomatic, 1.6% of general population
- etiopathogenesis: reflux, inflammation, induction of CDX2, METAPLASIA
- symptoms: GERD, asymptomatic, symptoms may improve in patients who develop BE
Barrett’s Esophagus: diagnosis
- 2 EGD’s with bx within 1 year (confirm dx; rule out PREVALEN DYSPLASIA)
Barrett’s esophagus: treatment
- PPI for GERD; ENDOSCOPIC ABLATIVE Tx or surgery for dysplasia/carcinoma
Surveillance of Barrett’s esophagus
- determined by absence or presence of dysplasia, grade of dysplasia
Complications of Barrett’s esophagus
- adenocarcinoma: 1/200 patients/year (.5%/year), RR=30-60
Frequency of surveillance based on grade of dysplasia in BE
- no dysplasia: q 3-5 years
- indefinite for dysplasia: rebiopsy after tx underlying inflammation
- low grade dysplasia: q 6-12 months
- high grade dysplasia: q 3 months
Intramucosal carcinoma
- high grade dysplasia
- managed w/ esophagectomy due to 40% “cancer” risk
- 2/3 of these cancers are intramucosal, associated with
Categories of esophageal diseases
V: vascular I: infectious/inflammatory T: traumatic A: anatomic M: metabolic I: idiopathic N: neoplastic
Presentation of adenocarcinoma
- 95% present with advanced full blown adenocarcinoma rather than presenting and then progressing to it
Treatment for adenocarcinoma
- first do chemoradiation
- second do esophagectomy
Incidence of esophageal cancer
- increasing at an alarming rate
- due to obesity epidemic
Squamous cell carcinoma: gross & histology
- fungating, friable tumor mass
- keratin pearls on histology
SCC vs. Adenocarcinoma
- SCC: etiology-tobacco, alcohol, hot beverages; not a major disease in the west
- adenocarcinoma: etiology-GERD, tobacco, obesity; much higher incidence
