Oesophagus and Stomach 3 and 4 - Pathology of oesophagus and stomach, dyspepsia and peptic ulcer disease Flashcards
What mucosa lines the normal oesophagus?
Stratified squamous epithelium
What tends to cause acute oesophagitis?
Rare but usually caused by corrosion following chemical ingestion or infection in immunocompromised patients e.g. candidiasis, herpes
What tends to cause chronic oesophagitis?
Reflux disease - “reflux oesophagitis)Rarely, caused by crohns
What is reflux oesophagitis?
Inflammation of oesophagus due to refluxed low pH gastric content
Microscopic appearance of reflux oesophagitis?
Basal zone epithelial expansion (hyperplasia)Intraepithelial neutrophils, lymphocytes and eosinophils
What is Barrett’s oesophagus?
Replacement of stratified squamous epithelium by columnar epithelium with intestinal metaplasia
How does the metaplasia occur in Barrett’s oesophagus?
Due to expansion of columnar epithelium from gastric glands or from submucosal glandsDue to differentiation from oesophageal stem cells
What is allergic oesophagitis?Other name
An inflammatory condition in which the walls of the oesophagus become filled with eosinophils”eosinophillic” oesophagitis
What type of patients does allergic oesophagitis tend to occur in?
Those with a personal/ family history of allergy e.g. asthmaYoungMales more than females
pH probe of allergic oesophagitis?
Negative for reflux
Blood test in a patient with allergic oesophagitis?
Increased eosinophils
Appearance of an allergic oesophagitis?
Corrugated or “spotty” oesophagus
Treatment for allergic oesophagitis?
Steroids/ chromoglycate/ montelukast
What benign tumours are most commonly found in the oesophagus?What are they associated with
Squamous papilllomaRareHPV
Other benign tumours of the oesophagus apart from squamous papilloma?
LeiomyomasLipomasFibrovascular polypsGranular cell tumoursVERY rare
What is the commonest type of oesophageal cancer in males?
Squamous cell carcinoma
Causes of squamous cell carcinoma?
Vitamin A, zinc deficiencyTannic acid/ strong teaSmoking, alcoholOesophagitisGenetic
What is commonest type of oesophageal cancer in caucasians?
Adenocarcinoma
Steps to developing adenocarcinoma of oesophagus?
genetics, reflux, etc. - chronic reflux oesophagitis - barretts oesophagus - low grade dysplasia - high grade dysplasia - adenocarcinoma
What type of cancers are the majority of oral cancers?
Squamous cell carcinoma
What parts of the mouth is it rare to develop cancer on?
Hard palateDorsum of tongue
Causes of squamous cell carcinoma of the oral cavity?
TobaccoAlcoholBetel quidViral? (HPV)Chronic infections?Nutritional deficiencies?genetics
Staging system for oral cancer?
TNM system
Treatment of oral cancer?
Surgery +/- adjuvant therapy
What is another name for dyspepsia?
Indigestion
What is dyspepsia?
pain or discomfort in the upper abdomen after eating and sometimes accompanied by nausea, vomiting or a feeling of unease or fullness
What is the name given to epigastric pain or burning?
Epigastric pain syndrome
What is the name given to postprandial fullness?
Postprandial distress syndrome
What is the name given to early satiety?
Postprandial distress syndrome
What are the 2 different categories of causes of dyspepsia?
Organic (25%)Functional (75%)
What are 3 organic causes of dyspepsia?
Peptic ulcer diseaseDrugs (esp NSAIDS, COX2 inhibitors)Gastric cancer
What is functional dyspepsia?
Same symptoms of dyspepsia but no evidence of culprit disease(associated with other functional gut disorders e.g. IBS)
Difference between dyspepsia/ indigestion and heartburn/ reflux?
Heartburn is an unpleasant condition that occurs when acid from the stomach leaks into the oesophagus and rises upwards to cause pain and discomfort in the chest. Indigestion is a general term for pain or discomfort felt in the stomach and under the ribs.
What are ALARM Symptoms related to dyspepsia?
AnaemiaLoss of weightAnorexiaRecent onset/ progressive symptomsMelaena/ haematemesisSwallowing difficulty
Action required if patient has dyspepsia with alarm symptoms?
Refer to hospital
Action if patient has dyspepsia with no alarm symptoms?
Check H pylori statusEradicate if infected (cures ulcer disease, removes risk of gastric cancer)If HP -ve, treat with acid inhibition as required
What is the Rome III diagnostic criteria for Functional dyspepsia?
Presence of at least one of the following:Bothersome postprandial fullnessEarly satiationEpigastric painEpigastric burningAndNo evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms Symptom onset 6 months ago with criteria fulfilled for past 3 months
What happens to patients with peptic ulcer diseases pain when they eat?
It is either aggravated or relieved
What type of course does peptic ulcer disease lead?
A relapsing and remitting chronic illness
Is peptic ulcer disease genetic?
Family history is common
What are 2 major causes of peptic ulcer disease?
H pyloriNSAIDspossibly also gastric dysmotility and outflow obstruction
What % of DU and GU does H pylori cause?
90% of DU60% of GU(NSAIDs cause most of the rest)
What is a peptic ulcer?
a lesion in the lining (mucosa) of the digestive tract, typically in the stomach or duodenum, caused by the digestive action of pepsin and stomach acid.
When is H pylori usually acquired?
Infancy
What is the appearance of H pylori?
Gram negative microaerophilic flagellated bacillus
How is H. pylori spread?
Oral-oral/ faecal-oral route
What are the consequences of being infected by H pylori?
Usually no pathology20-40% = peptic ulcer disease1% = gastric cancer
What do G cells in the stomach do?
Produce gastrin in response to a higher pH (this is a hormone that stimulates the parietal cells to increase secretion of HCl)
How does H pylori affect gastrin production?
It increases the production of gastrin and therefore increases acid production and leads to an ulcer
How does intense infection with H pylori affect the stomach?
It causes gastric atrophyThis results in the distal part of the stomach producing lots of gastrin trying to drive the stomach to produce acid but they can’t due to atrophy - this can lead to gastric carcinoma
What mucosal appearance does chronic gastritis tend to have?
A cobble stone appearance
Diagnosis of H pylori infection? (4)
Gastric biopsy (urease test, histology, culture/ sensitivity)Urease breath test (need to stop PPI) (helicobacter produces large amounts of urease)FAT (faecal antigen test)Serology (IgA) - not accurate with increasing patient age so doesn’t tend to get done
Treatment of peptic ulcer disease?
All PPIAll tested for H pyloriIf +ve eradicate and confirmWithdraw NSAIDsChange lifestyle e.g. dietSurgery is sometimes performed
Do PPIs and H2RAs heal ulcers?
yes - PPIs do it better
Eradication therapy for H pylori?
Tripel therapy for 1 week = commenest2 week regimens = higher eradication rates but poorer compliance (dual therapy is not recommend)
Triple therapy for H pylori?
PPI bd + amoxicillin 1g bd + clarithromycin 500mg bdPPI bd + metronidazole 400mg bd + clarithromycin 250mg bdUsually for 1 week but there are 2 week regimens
Complications of peptic ulcer disease?
Anaemia, bleeding, perforation (doesn’t happen often), gastric outlet/ duodenal obstruction - fibrotic scar
Post-therapy follow up for DU?
Uncomplicated DU requires no f/u unless ongoing symptoms
Post-therapy follow up for GU?
F/u endoscopy at 6-8 weeksEnsure healing and no malignancy
does achlorhydria increase risk of gastric cancer?
Yes e.g. pernicious anaemia, previous gastric surgery
What is Correa’s hypothesis of gastric cancer?
A combination of H pylori, smoking and salt causes the following changes:Normal - chronic gastritis - atrophy - intestinal metaplasia - dysplasia - neoplasia
What type of patients with H pylori are prohibited from developing gastric cancer?
Those with H/ pylori who have had a previous peptic ulcer
