1. Incomplete LES relaxation 2. Increased LES tone 3. Aperistalsis of the esophagus

Path stomach and esophagus Flashcards by Tiffany Reid

Normal tissue in an abnormal location

Ectopia (heterotopia)

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Incomplete development of something (ex: esophagus)

Atresia

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Connection between two organs that is not normal (ex: esophagus and trachea)

Fistula

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These two conditions are uncommon, are discovered shortly after birth because babies regurgitate their food

Atresia and fistula

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Ledge-like protrusions of mucosa, usually in the upper esophagus

Esophageal webs

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Acquired cases of esophageal webs can result from:

long standing reflux esophagitis
Plummer-Vinson syndrome: Fe deficiency, glossitis, cheilosis
Graft versus host disease
Blistering diseases

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Similar to esophageal webs but thicker and usually distal.

Esophageal rings

Schatzki’s rings

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When above the GE junction, esophageal rings have ___ epithelium and they are called ___ rings.
Below?

Squamous, A rings

Gastric-cardiac type, B

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Focal outpouchings of mucosa, lined by squamous mucosa

Diverticula

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Zenker vs. Traction vs. Epiphrenic diverticula

Z: upper esophagus, focal weakness in the wall between inferior pharyngeal constrictors and cricopharyngeus. Common
T: mid-esophagus, inflammatory lymph nodes
E: immediately above lower esophageal sphincter. Rare

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Tortuous, dilated veins with distal esophageal and proximal gastric submucosa, with ulceration and inflammation

Esophageal varices

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Esophageal varices result from ___

Portal hypertension, usually from alcohol cirrhosis

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Longitudinal tears near GE junction, usually across the junction

Symptoms?
Common in ___

Mallory-Weiss tear

Severe retching/vomiting
binge drinkers

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Transmural tearing and rupture of distal esophagus (usually from retching/vomiting)

Symptoms?

Boerhaave syndrome

Chest pain, tachypnea, shock (can look like myocardial infarction)

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Sac-like dilation of stomach and herniation of proximal stomach above the diaphragm

Resembles reflux
Common

Hiatal hernia

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Fibrous thickening of the wall of the esophagus with atrophy of muscularis propria

Usually due to what?

Esophageal stenosis

Reflux, radiation, caustic injury, scleroderma

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Achalasia triad

Incomplete LES relaxation
Increased LES tone
Aperistalsis of the esophagus

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Symptoms of Achalasia

Dysphagia
Difficulty belching
Chest pain

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The result of distal esophageal inhibitory neuronal degeneration
Vs.
The result of other diseases that damage or infiltrate the myenteric plexus

Primary achalasia

Secondary achalasia

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Chagas disease causes:

Secondary achalasia by way of:
Destruction of the myenteric plexus
Failure of peristalsis
Esophageal dilation

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3 forms of infective esophagitis

HSV
CMV
Candida

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HSV caused esophagitis symptoms

Punched out ulcers
Cowdry type A inclusions
Multinucleated giant cells

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CMV caused esophagitis symptoms

Linear ulcers
Large cells
Large intranuclear inclusions

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Candida caused esophagitis symptoms

Pseudomembrane a
Ulcer w/necrotinflammatory debris
Budding yeast and pseudohyphae by PAS or GMS stains

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What is the most common cause of infections esophagitis? Most common cause of esophagitis overall?

Candida | Reflux

Symptoms of reflux caused esophagitis

``` Dysphagia Heartburn Regurgitation Hematemesis Melena ```

Microscopic morphology of reflux caused esophagitis

- Inflammatory cells in squamous epithelium - basal zone hyperplasia - elongation of lamina propria papillae

Single most important risk factor for esophageal adenocarcinoma

Barrett esophagus | -complication of reflux

Two criteria for dx of Barrett esophagus

1. Endoscopic evidence of columnar epithelium above GE junction 2. Intestinal metaplasia (goblet cells) in the columnar epithelium

Adenocarcinomas usually arise in what part of the esophagus? | In what populations is it more common?

Distal >40 y/o Men>women

Genetic alterations present in esophageal adenocarcinomas:

1. Inactivation of tumor suppressors TP16, TP27, TP53, and APC 2. Overexpression of cyclin D1, growth factor receptors EGFR and ERBB2

Squamous cell carcinoma of the esophagus is usually in what part of the esophagus? In what populations is it more common?

Middle 1/3 >50 Men>women

Onset of squamous cell carcinoma of the esophagus:

Dysphagia Odynophagia Obstruction

Risk factors for squamous cell carcinoma:

``` *Smoking and alcohol* Radiation Thermal injury Diets high in pickled vegetables, moldy food, smoked foods, N-nitrosamines Diets low in antioxidants Genetic abnormalities HPV ```

Genetic alterations present in esophageal squamous cell carcinomas

1. Overexpression of cell cycle regulatory proteins such as cyclin D1 and cyclin E 2. Inactivation of tumor suppressors such as p53

Congenital vs acquired esophageal conditions

Congenital: Atresia, fistula, heterotropia Acquired: Rings, webs, diverticula, varices

Incomplete formation of the diaphragm with herniation of abdominal viscera into the thoracic cavity

Congenital diaphragmatic hernia | *if severe causes pulmonary hypoplasia

Congenital anterior abdominal wall defect due to incomplete closure of ab muscles 10 weeks gestation

Omphalocele

Omphaloceles are usually associated with various ___

Trisomies (13, 18, 21) | and Beckwith-Wiedemann syndrome

Congenital anterior ab wall defect, involves ALL layers of ab wall 6-8 weeks gestation

Gastroschisis

Hyperplasia and thickening of pyloric muscularis propria with stenosis of pyloric region and obstruction of gastric outflow

Congenital hypertrophic pyloric stenosis *projectile vomiting, an masses

___ is the most common cause of chronic gastritis & peptic ulcer disease

H. pylori

___ and ___ have decreased gastric acid secretion and higher risk for adenocarcinoma

Pangastritis | Multifocal atrophic gastritis

Neutrophils are usually a sign of what type of gastritis?

Active chronic gastritis | NOT acute gastritis

Stomach diseases associated with H. pylori

``` Chronic gastritis Peptic ulcer disease Atrophic gastritis Gastric adenocarcinoma Gastric MALT lymphoma ```

Four layers in a well developed peptic ulcer

1. Surface coat of neutrophils, necrotic debris, and bacteria 2. Fibrinoid necrosis 3. Granulation tissue 4. Fibrosis replacing the muscle wall extending into the subserosa

Characterized by 1. antibodies to parietal cells, with resulting achlorhydria (decreased production of acid) 2. Reduced pepsinogen 3. B12 deficiency, antibodies to intrinsic factor 4. Hypergastrinemia

Autoimmune gastritis

Immune Affects fundus Assc. w/ anti-parietal cell antibodies May evolve into pernicious anemia

Atrophic gastritis Type A

Non-immune Begins in antrum and progresses to fundus H. pylori mainly is the cause

Atrophic gastritis Type B

Diagnostic criteria for atrophic gastritis

At least one of the following: 1. Glandular loss replaced by fibrosis 2. Intestinal metaplasia

Examples of hypertrophic gastropathies

Ménétrier disease | Zollinger-Ellison disease

from gastrin secreting tumors (gastrinomas) of small intestine or pancreas Duodenal ulcers and/or chronic diarrhea Malignant, but slow growing

Zollinger-Ellison syndrome

``` Complex of giant gastric folds Low acid pr fiction Protein loss Pit hyperplasia Middle aged adults Excess TGF-alpha Weight loss, vomiting, diarrhea, ab pain Loss of parietal and chief cells leads to hypochlorydria ```

Menetrier disease

Second most common gastric polyp Benign Common in 65-75 y/o Most are single, asymptomatic, and occur in antrum Associated with chronic gastritis from H. pylori

Inflammatory/hyperplastic polyps

Morphology of inflammatory/hyperplastic polyps

1. elongated, tortuous or dilated pits lined by foveolar epithelium with fundic or pyloric glands 2. Lamina propria has mixed inflammatory cells 3. May regress when underlying cause is treated

Benign cystic and polypoid transformation of oxyntic mucosa - most common type of gastric polyp - single or multiple in fundic mucosa - limited to body and fundus

Fundic gland polyps

Polyp that occurs sporadically and in association with familial associated polyposis (FAP)

Fundic gland polyps

Increased incidence of ___ can occur with use of PPIs

Fundic gland polyps | *inhibited acid secretion can result in increased gastric secretion and oxyntic hyperplasia

These polyps can also be seen in Zollinger-Ellison syndrome

Fundic gland polyps

1. Neoplastic polyps are also called ___ 2. They are associated with ___ 3. More common in the ___ 4. Nuclei are __ 5. Can have a stalk 6. Usually single 7. Dysplasic

1. polypoid gastric dysplasia 2. H. pylori gastritis, FAP, fundic gland or hyperplastic polyps, Peutz-Jeghers, and juvenile polyposis syndromes 3. Antrum 4. Enlarged, elongated, hyperchromatic, pseudostratified

Almost all intestinal adenocarcinomas arise from ___

Generative (basal) cells of foveolae | *usually in background of chronic gastritis and intestinal metaplasia with dysplasia

External risk factors associated with stomach intestinal type adenocarcinomas:

1. Diets high in nitrates, smoked and salted foods, and pickled vegetables 2. Diets low in fresh fruits and green leafy vegetables 3. Smoking 4. Low socioeconomic status

Host risk factors associated with stomach intestinal type adenocarcinomas:

1. Chronic gastritis with intestinal metaplasia associated with H. pylori or autoimmune gastritis 2. Partial gastrectomy 3. Gastric adenomas

Polyps not associated with H. pylori gastritis or Barrett esophagus Also called linitis plastics, or signet ring adenocarcinoma *no discrete mucosal mass

Diffuse type

Types of stomach lymphomas

1. Extranodal marginal zone lymphoma of MALT type | 2. Diffuse large B cell lymphoma

GIST

Gastrointestinal stromal tumor - mutations in receptor tyrosine kinase KIT - express c-kit (CD117) - may be treated with imatinib, which inhibits c-kit