GIS10 Pathology Of The Esophagus And Cardia

Question 1

Esophagus pathology

Answer 1

1. Congenital anomalies
2. Esophagitis (inflammation)
3. Barrett’s esophagus
4. Neuromuscular dysfunction
5. Neoplasia

Question 2

Congenital anomalies of esophagus

Answer 2

1. Esophageal atresia (failure to form)
2. Tracheo-esophageal fistula (abnormal connection)
3. Duplication

Question 3

Esophagitis

Answer 3

1. Reflux esophagitis
2. Infective
   - candida
   - HSV
   - CMV
3. Irritants, radiation, prolonged gastric intubation

Question 4

Reflux esophagitis

Answer 4

• frequent and prolonged reflux of gastric contents in the esophagus —> acute esophagitis + ulceration
• markedly red esophagus
• heartburn, regurgitation

Causes:

1. ***Hiatus hernia (stomach slip through diaphragm)
2. Increased ***intra-abdominal pressure (obesity, frequent hard coughing, heavy lifting)
3. Loss of ***diaphragmatic muscular tone with ageing
4. Abnormal ***upper GI motility

• **Histological features:
  1. Hyperplasia of squamous epithelium
  2. Lots of lymphocyte and neutrophil (Polymorphs)

Question 5

Infective esophagitis

Answer 5

Diagnosis: Biopsies

1. Fungal esophagitis
   - Candida, Aspergillus, Mucor
   - markedly red esophagus
   - gastric-esophageal junction blurred
   - in immunocompromised patient
2. Viral esophagitis
   - HSV —> **darkened esophagus
   - CMV —> **enlarged cell

Question 6

Barrett’s esophagus

Answer 6

• at lower end of esophagus
• result of prolonged reflux esophagitis —> markedly red esophagus
• Squamous mucosa replaced by metaplastic Columnar epithelium of intestinal type —> more resistant to gastric juice

- Hallmark:
—> **Intestinal metaplasia
—> presence of goblet cells (*Glandular / Simple Columnar epithelium)

• complications: malignancy of lower 1/3 of esophagus (***Adenocarcinoma)

Question 7

Neuromuscular dysfunction / Achalasia

Answer 7

• failure of relaxation of lower esophageal sphincter during swallowing + no peristalsis (aperistalsis)

Reason:
- ↓ no. / complete absence of myenteric ganglion cells in the esophagus proximal to the LES
—> loss of intrinsic inhibitory (parasympathetic) innervation of the LES and smooth muscle coat of esophagus
—> unable to relax

Progression:

• ***Dilation of esophagus (proximal end)
• ***Fibrosis and thickening of esophagus

Presentation:

• Progressive ***dysphagia
• ***Regurgitation

Treatment:
- may need resection of esophagus to treat abrupt narrowing of opening

Patient group:

• middle life
• young adulthood
• infancy / childhood

Question 8

Neoplasia of esophagus

Answer 8

Benign:

• small, asymptomatic
  1. Squamous papilloma (epithelial tumour)
  2. Lipoma (fat tissue tumour)
  3. Leiomyoma (smooth muscle tumour)

Malignant:
**1. Squamous cell carcinoma (SCC) (commonest, usually occurs in middle esophagus)
—> irregular edges / surface, dark edges due to **necrosis
—> presence of **intercellular bridges and **keratin production
***2. Adenocarcinoma (Barrett’s esophagus, lower 1/3, ∵ turned into Columnar epithelium)
3. Others (small cell carcinoma)

Etiology:

• ***Diet (restricted diet of cornmeal and pickled vegetable, nitrosamine, trace element deficiency, fungal contaminants)
• Chronic alcoholism + smoking
• Barrett’s esophagus
• Achalasia (esophageal disorder)
• Genetic prediposition

***Gross appearance:
1. Ulcerative (commonest)
2. Polypoid / Fungating
—> new vessel formation cannot keep up with lesion growth
—> ischaemic —> necrotic —> ulcerative
3. Sclerosing / Constrictive

ALL giving rise to progressive **dysphagia due to **obstruction / constriction

Spread:

• Direct: Lungs (esophageal wall perforated), Aorta (rupture into aorta with fatal hematemesis)
• Lymphatic: regional lymph nodes, submucosal spread —> multiple tumour nodules
• Haematogenous spread: liver, brain

Question 9

Cardia pathology

Answer 9

1. Cancer
   - Adenocarcinoma (most common) (predisposition: Barrett’s esophagus)
2. Gastritis
3. Peptic ulceration

Question 10

Esophageal varices

Answer 10

due to Portal hypertension from liver cirrhosis