Pathology -- Diseases of the Upper GI Tract Flashcards
Most common cause of esophagitis
Reflux esophagitis – gastroesophageal reflux disease
3 infectious etiologies of esophagitis
- Candida
- Herpes simplex
- Cytomegalovirus
3 miscellaneous causes for esophagitis
- Radiation
- Crohn’s disease
- Graft-vs-host disease
3 causes of GERD
- Abnormal tonus of lower esophageal sphincter
- Hiatal hernia
- Diabetic neuropathy
Symptoms of GERD
- Asymptomatic
- Heartburns
- Dysphagia
- Chest/epigastric pain
What does endoscpoic examination show in the event of GERD?
Erythema
In severe cases, erosins/ulcers
What can complicate GERD and what can it lead to?
Strictures –> development of Barrett esophagus
Treatment for GERD
Proton pump inhibitor treatment
Describe the histology of GERD
What leukocyte may appear intraepithelialy in GERD?
Eosinophils
Define esinophilic esophagitis
Allergic inflammatory disease of the esophagus
3 symptoms of eosinophilic esophagitis
- Dysphagia
- Food impaction
- GERD-like symptoms
Describe the histology of esoinophilic esophagitis
Numerous intraepithelial eosinophils
What is a differential diagnosis with GERD?
Eosinophilic esophagitis
Differentiate between the location of effect of eosinophilic esophagitis vs. GERD
EE = entire esophagus
GERD = Distal esophagus
Differentiate between the quantity of intraepithelial esoniphils in EE vs. GERD
EE = numerous
GERD = Much fewer than EE
Differentiate between the treatments for EE vs. GERD
EE = corticosteroids
GERD = proton pump inhibitors
Who may be affected by herpes esophagitis?
May occur in otherwise healthy individuals, but usually seen with immunosuppression:
- AIDS
- Transplantation
- Malignancies
Findings on endoscopy for herpes esophagitis
Vesicles followed by ulcers
5 microscopic findings for herpes esophagitis
- Inflammation (neutrophils, histiocytes)
- Cytopathic effect in epithelial cells
- Ground glass viral inclusions
- Multinucleation
- Nuclear molding
Define Barrett esophagus
Replacement of the normal squamous mucosa of the lower esophagus with columnar-type epithelium (intestinal metaplasia)
Symptoms of Barrett esophagus
Since it’s secondary to GERD, clinical symptoms are those of GERD
Endoscopic findings of Barrett esophagus
Mucosa of the BE is salmon-pink and velvety
Potential consequence of Barrett esophagus
A minority of patients will develop esophageal adenocarcinoma (BE –> dysplasia –> adenocarcinoma)
Describe the histology of Barrett esophagus
In this example, intestinal type simple columnar epithelium is present in the middle with frequent goblet cells. Squamous esophageal epithelium present to left and right
Describe the histology of Barrett esophagus with low-grade dysplasia
In this example, squamous epothelium is to the left and glandular epithelium (adenocarcinoma) to the right. On lower power, the glandular epithelium is much darker than that of the intestinal metaplasia
Why is the glandular epithelium of low-grade dysplasia in Barrett esophagus darker than that of regular Barrett esophagus
- Lack of maturation = lesser cytoplasm
- Nuclear enlargement
- Nuclear stratification
When is H pylori acquired
In childhood (causes perisistent infection in most people)
Clinical manifestations of H Pylori
- Asymptomatic OR dyspepsia AND/OR epigastric pain
- May present with peptic ulcer
How does H Pylori infect a patient?
By attaching to the mucosal epithelial cells (stained brown here)
5 complications of H Pylori
- Gastric atrophy
- Intestinal metaplasia
- Peptic ulcer
- Gastric cancer (very strong association with the intestinal type of gastric cancer)
- Lymphoma
Describe the histology of chronic active gastritis secondary to H pylori infection
- “Chronic” = plasma cells in lamina propria
- “Active” = neutrophils infiltrating the lamina propria and glands
Define autoimmune gastritis
Autoimmune process directed against gastric parietal and chief cells
What does autoimmune gastritis lead to?
Chronic inflammation of gastric body with loss of parietal and chief cells –> Achlorhydria and megaloblastic anemia (secondary to deficient secretion of intrinsic factor)
Define a peptic ulcer
Breach in the integrity of the mucosa extending beyond the muscularis mucosae
Cause of peptic ulcer
Imbalance between the damaging forces and the defense mechanisms of the mucosa
Give the 3 locations of peptic ulcer disease in decreasing order of frequency
- Duodenum
- Stomach
- Esophagus (in the setting of GERD)
Define mucosal erosion
Smaller than a peptic ulcer; damage is limited to the mucosa
Defense mechanisms to prevent peptic ulcers (4)
- Surface mucus
- Secretion of bicarbonate which maintains a higher pH within the mucus than in the gastric lumen
- Epithelial regneration
- Prostaglandins (reduce acid secretion, arguably cytoprotective)
Damaging forces that can lead to peptic ulcer disease (7)
- Gastric acidity
- Peptic enzymes
- H pylori infection
- NSAIDs
- Bile reflux into the stomach (duodenal-gastric reflux) – for gastric ulcers only
- GERD – for cardia and lower esophageal ulcers
3 macroscopic features of peptic ulcer disease
- Regularly shaped walls, margins at the same level with the surroudning mucosa (“punched out” ulcer)
- Clean sometimes hemorrhagic base
- Gastric folds reach the edge of the ulcer
Most important differential diagnosis for peptic ulcers
Ulcerated tumor (most frequently, an ulcerate adenocarcinoma)
Why is the differential diagnosis for peptic ulcers especially important in the stomach?
Duodenal neoplasias are very rare and duodenal ulcers are almost always peptic in nature
What does the differential diagnosis for peptic ulcer disease depend on?
Endoscopic features
Microscopy
Differentiate between the size of a peptic ulcer vs. an ulcerated tumor
PU = usually small (<2 cm)
UT = usually large (>2 cm)
Differentiate between the shape of a peptic ulcer vs. an ulcerated tumor
PU = Round to oval, regular “punched out” borders
UT = More irregular in shape
Differentiate between the borders of a peptic ulcer vs. an ulcerated tumor
PU = edges at the same level with surrounding mucosa or just slightly elevated
UT = elevated, thick borders
Differentiate between the base of a peptic ulcer vs. an ulcerated tumor
PU = smooth and clean
UT = irregular and necrotic
Differentiate between the formation of a peptic ulcer vs. an ulcerated tumor
PU = imbalance between defensive and damaging forces
UT = tumor forms in epithelium and grows –> becomes necrotic and the pus drains/pieces break off
