Pathology - Amitai Flashcards
What is the blood supply and ennervation of the esophagus?
Upper/cervical:
Esophageal branch of inferior thyroid artery, superior left bronchial artery, right bronchial artery, inferior left bronchial artery, aortic esophageal arteries.
Recurrent laryngeal nerves
Abdominal:
Inferior phrenic artery, left gastric artery
Vagus nerves (anterior esophageal plexus), thoracic chain
Drained by corresponding veins and hemi/azygos.
Barrett’s Esophagus
Complication in 10% of symptomatic GERD patients over time.
Pathogenesis not clear, begins with activation of protooncogenes and disabling of tumor suppressor genes.
Think alteration in the differentiation program of stem cells of Eosph. Mucosa., normal esophageal lining, in which normal squamous epithelium is replaced by metaplastic columnar epithilium (gastric metaplasia).
Clinical: age 40 to 60 years
Highest among white males.
Single most important risk factor for esophageal adenocarcinoma. (twice relative risk of esophageal cancer, 30-40 times increased rate in long segment disease).
Criteria for diagnosis of BE are:
A) Endoscopic evidence –columnar epithelial lining above the GE Junction (normally squamous cells).
B) Histological evidence –intestinal metaplasia in the specimen from the columnar epithelium
Reflux esophagitis.
1) Numerous eosinophils within the squamous cells
2) elongation of the lamina propria papillae,
3) basal zone hyperplasia
Linear dark blue submucosal dilated veins known as esophageal varices.
Inflammation and hemorrhage is seen here in the region of a ruptured varix of the esophagus.
Types of tumors of the GI system
Benign:
Leiomyomas
Lipomas; pedunculated or fibrovascular polyps
Squamous papillomas.
Inflammatory pseudo- tumors.
Malignant:
Squamous Cell Carcinoma
Adult males predominant in Blacks in the US and worldwide.
Most common type of carcinoma of Eosophagus in the US.
Adenocarcinoma
Boerhaave’s syndrome
Spontaneous perforation of the esophagus typically follows large intake of food, followed by violent retching and vomiting
The most common site of rupture is 3-5 cm above the GEJ on the left posterolateral aspect
The 2nd most common site is the mid-thoracic esophgus on the right side at the level of the azygos vein
Sudden onset of crepitus is a classic sign. Also can have widening of mediastinum and left pleural effusion
Late rupture:
resect the perforated site
spitz fistula (exteriorize proximal)
close the distal end
mediastinal external drainage
feeding jejunostomy
delayed reconstruction with colon or jejunal interposition
What is the most common cause of esophageal stricture in young people?
Others?
Chemical injury from exposure to gastric juice, medication or caustic agents.
medication induced strictures typically occur in the mid-esophagus
Peptic strictures usually occur in the distal esophagus
caustic strictures can involve the entire esophagus, or segments at any level.
pliable, unfixed, short strictures are often dilated
fixed strictures may require surgery
Esophageal and Zenker’s Diverticulum
commonly associated with motor dysfunction and are usually acquired
Pulsion diverticula develop from protrusion of the mucosa and submucosa through a defect in the musculature
Traction diverticula result from pulling on the esophageal wall by scarred or inflamed adjacent tissue (typically mediastinal lymph nodes). True, usually lateral in midesophagus. due to inflammation, granulomatous disease, or tumor
Rx: excision and primary closure, may need palliative therapy if due to invasive cancer
Zenker’s:
most common type
a false diverticulum (lack muscularis layer)
pulsion type
more common in men
arises in the posterior midline of the neck above the cricopharyngeus muscle and below the pharyngeal inferior constrictor (i.e. posterior)
Rx: resection and cricopharyngeal myotomy
Zenker’s itself can either be resected or suspended (removal of diverticula not necessary)
Epiphrenic Diverticulum:
rare, associated with esophageal motility disorders
most common in the distal 10 cm
Dx: esophagram and manometry
Rx: diverticulectom and long esophageal myotomy on the side opposite the diverticulectomy
GERD properties, assessment and treatment
Substernal burning after meals or at night is the most common symptom
Initial management for mild reflux symptoms is conservative:
Topical agents (antacids) weight reduction
dietary changes (caffeine, ETOH) smoking cessation
avoid laying down after meals elevation of HOB
Reassess in 4-6 weeks, if not improved, more aggressive medical therapy is indicated.
PPI block parietal cell hydrogen pump action, resulting in healing in 80% of pts with erosive esphagitis
Studies to work-up GERD include the following options, aimed at assessing both esophagitis and esophageal function:
EGD with biopsy (to confirm and rule out Barrett’s esophagus)
24 hr pH testing
esophageal manometry
Barium swallow under real-time radiographic observation
Gastric emptying study
Up to 50% of GERD pts do not have gross evidence of esophagitis at EGD.
Chronic gastritis
Chronic inflammatory cell infiltration
Mucosal atrophy
Intestinal (goblet cell) metaplasia
Seen in Helicobacter (prominent neutrophil infiltrate) and autoimmune gastritis (not chemical)
Chemical gastritis (not seen here):
Commonly seen with bile reflux (toxic to cells)
Prominent hyperplastic response (inflammatory cells scanty)
With time – intestinal metaplasia
