Lecture 79 - Path of Esophageal Disease Flashcards
Normal Histology of the esophagus:
what type of epithelium is the mucosa?
whats missing form the adventia? why is this important?
Mucosa — non keratinized stratified squamous epithelium
Adventitia: Lack's Serosa Therefore easier for cancers to spread once there
Normal Anatomy/Function
– what are three areas of anatomical narrowing in the esophagus?
Three Anatomical Narrowings: Cricoid Carilage, Aortic Arch/Bronchial bifurcation, Diaphragm
Achalasia:
pathophysiology?
what is seen on histo?
what infection may be seoncdary cause of achalasia
Failure of relaxation of the LES due to loss of myenteric (auerbach) plexus
Secondary achalasia – may arise from T. Cruzi (chagas) or malignancy
Histological findings of GERD?
what else might be on the ddx?
DDx:
Eosinophilic Esophagitis – (EoE)
Chemical Injury, Infectious esophagitis, GERD with Barrett’s Esophagus
Mucosal injury and repair; inflammation (typically eosinophilic)
Decreased thickness of surface over papillae
Prominent basal layer (stem cells)
what % of GERD patients get barrett’s esophagus?
what is barrett’s esophagus?
10% of patients with GERD
Over time: metaplasia to an epithelium more like the intestine which is better equipped to handle acid
Metaplasia: Stratified squamous epithelium —> non ciliated columnar epithelium with goblet cells
May progress to dysplasia and adenocarcinoma
what are the required findings to make a diagnosis of Barrett’s Esophagus?
Dx Requirements:
1) endoscopy appearance of pink/salmon columnar mucosa in tubular esophagus, (but just bc it is columnar doesn’t mean its intenstinal (could be gastric))
2) Histological findings of intestinal metaplasia — Glandular epithelium with Goblet Cells
what is common mutation in dysplasia in the progression of BE to carcinoma?
what is this progrsesion
P53 mutation – common and early event
BE Metaplasia—> Low grade dysplasia –> high grade dysplasia –> Adenocarcinoma
features of low grade dysplasia ?
eatures which indicated Increased replication at the expense of function:
Increased cell turn over – dark nuclei – “picket fence”
Mucin depletion
Mitoses moving up the gland
Intestinal metaplasia with pale goblets cells
Features of high grade dysplasia:
High Grade Dysplasia \
Architectureal distortion -- cribiforming "swiss-cheese" look (cribriform = pierced with small holes) Severe cytological and nuclear abnormalities --- loss of polarity; high variability
lots of mitosis
Adenocarcinoma of the Esophagus
- associatd with what precursor?
- histology?
- what third of the esophagus does it commonly occur?
Risk factors: Reflux and barrett’s esophagus (95% of cases)
Derives from glandular mucosa --> glandular dysplasia --> Cancer Invasion of atypical glands into underlying tissues Distal third of esophagus
Squamous Cell Carcinoma –
risk factors?
Histology?
Risk factors: Smoking, drinking, acid ingestion, and caustic burns, exposure increases (such as in achalasia)
Dysplasia: Squamous cells with impaired maturation with atypia
Carcinoma: cells break out of normal distribution, invade underlying tissues
Staging of Esophgeal cancers:
where are the first mets?
- Depth of invasion – (for GI tract cancers in general)
Risk of mets increase with increased depth of invasion === confers to prognosis
– if it invades to surrounding structurs — unresectable
First mets are usually to LNs
three most common agents of infectious esophagitis?
Candida – most commony
HSV – 2nd
CMV
Gross and Histological findings of candiasis of infectious esophagitis?
what specific stain can be used?
Gross: White plaques – disruption and falling off the sqmamous
Micro – squamous debris, active esophagitis (PMNs),
GMS Stain -- fungal forms are black
HSV infectious esophagitis –
Gross:
where should the bx be taken from?
Indicative histological finding?
what specific stain can be used?
ulcers and erosion
virus will be at the interface of the ulcer and squamous epithelium
Micro: Multinucleated cells at the interface
Immuno stain for herpes virus:
CMV infectious esophagitis? gross path? where should the bx be taken from? Histo? specific stain ?
Gross: Punched out lesions
The virus does actually live in the ulcer bed – so bx the Ulcer itslef
Micro – PMNs, eosinophils, inflammation of the lamina propria
Immunostain
Three causes of chemical esophagitis?
where does pill esophagitis most commonly occur?
GERD
Caustic Injuries:
Pill Esophagitis -- Cricoid Carilage, Aortic Arch/Bronchial bifurcation, Diaphragm
Eosinphilic Esophagitis —
associated with?
prognosis?
Histology?
treatment?
Allergic Disease; associated with other allergic conditions
May cause strictures, but doesn’t seem to progress to anything terrible (no cancers)
Features; Lots of eosinophils
EoE cluster together;
Treatment: Swallowed Steroids;
In what “systemic” conditons may esophagitis also occur?
Crohns’
Graft Vs Host Disease
Dermatologic Conditions – Stephen Johnson, Pemphigoid, pemphigus
Varices of the esophagus?
cause?
presentaiton?
do you biopsy?
what do they look like?
Path: Portal HTN is the major cause;
DO NOT Bx (hemorrhage)
Overlying mucosa is normal
Often asymptomatic until they rupture and bleed – at that point they have high mortality;
Mallory Weiss Syndrome
what is it?
who is at risk?
where does it occur?
presentation?
Not full thickness tear at the GE junction— involves the mucosa and submucosa
Can be spontaneous, but the classic association is repeated vomiting (alcoholism, bulemia) Presentation: Painful hematemesis
Perforation: Full Thinckness –
4 causes:
which has the best prognosis?
which might have the worst complications?
iatrogenic – which have a good outcome
traumatic, Neoplastic
associated with repeated vomiting (Boerhaave Syndrome) – more prone to complications
Boerhaave Syndrome
what is it?
presentation?
treatment?
Imaging findings?
whats different when doing the esophagram/
Perforation: Full Thinckness of the distal esophagus
Boerhaave -- Severe tearing pain
surgical emergency
XR -- look for free air spaces Esophagram -- use Gastrographin (water soluble contrast agent); Do not use Barium (bc if it gets out of the esophagus, can cause fibrosis)
