Pathology -- Diseases of the Upper GI Tract

Question 1

Most common cause of esophagitis

Answer 1

Reflux esophagitis – gastroesophageal reflux disease

Question 2

3 infectious etiologies of esophagitis

Answer 2

• Candida
• Herpes simplex
• Cytomegalovirus

Question 3

3 miscellaneous causes for esophagitis

Answer 3

• Radiation
• Crohn’s disease
• Graft-vs-host disease

Question 4

3 causes of GERD

Answer 4

• Abnormal tonus of lower esophageal sphincter
• Hiatal hernia
• Diabetic neuropathy

Question 5

Symptoms of GERD

Answer 5

• Asymptomatic
• Heartburns
• Dysphagia
• Chest/epigastric pain

Question 6

What does endoscpoic examination show in the event of GERD?

Answer 6

Erythema

In severe cases, erosins/ulcers

Question 7

What can complicate GERD and what can it lead to?

Answer 7

Strictures –> development of Barrett esophagus

Question 8

Treatment for GERD

Answer 8

Proton pump inhibitor treatment

Question 9

Describe the histology of GERD

Answer 9

Question 10

What leukocyte may appear intraepithelialy in GERD?

Answer 10

Eosinophils

Question 11

Define esinophilic esophagitis

Answer 11

Allergic inflammatory disease of the esophagus

Question 12

3 symptoms of eosinophilic esophagitis

Answer 12

• Dysphagia
• Food impaction
• GERD-like symptoms

Question 13

Describe the histology of esoinophilic esophagitis

Answer 13

Numerous intraepithelial eosinophils

Question 14

What is a differential diagnosis with GERD?

Answer 14

Eosinophilic esophagitis

Question 15

Differentiate between the location of effect of eosinophilic esophagitis vs. GERD

Answer 15

EE = entire esophagus

GERD = Distal esophagus

Question 16

Differentiate between the quantity of intraepithelial esoniphils in EE vs. GERD

Answer 16

EE = numerous

GERD = Much fewer than EE

Question 17

Differentiate between the treatments for EE vs. GERD

Answer 17

EE = corticosteroids

GERD = proton pump inhibitors

Question 18

Who may be affected by herpes esophagitis?

Answer 18

May occur in otherwise healthy individuals, but usually seen with immunosuppression:

• AIDS
• Transplantation
• Malignancies

Question 19

Findings on endoscopy for herpes esophagitis

Answer 19

Vesicles followed by ulcers

Question 20

5 microscopic findings for herpes esophagitis

Answer 20

• Inflammation (neutrophils, histiocytes)
• Cytopathic effect in epithelial cells
• Ground glass viral inclusions
• Multinucleation
• Nuclear molding

Question 21

Define Barrett esophagus

Answer 21

Replacement of the normal squamous mucosa of the lower esophagus with columnar-type epithelium (intestinal metaplasia)

Question 22

Symptoms of Barrett esophagus

Answer 22

Since it’s secondary to GERD, clinical symptoms are those of GERD

Question 23

Endoscopic findings of Barrett esophagus

Answer 23

Mucosa of the BE is salmon-pink and velvety

Question 24

Potential consequence of Barrett esophagus

Answer 24

A minority of patients will develop esophageal adenocarcinoma (BE –> dysplasia –> adenocarcinoma)

Question 25

Describe the histology of Barrett esophagus

Answer 25

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

Question 26

Describe the histology of Barrett esophagus with low-grade dysplasia

Answer 26

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

Question 27

Why is the glandular epithelium of low-grade dysplasia in Barrett esophagus darker than that of regular Barrett esophagus

Answer 27

* Lack of maturation = lesser cytoplasm * Nuclear enlargement * Nuclear stratification

Question 28

When is H pylori acquired

Answer 28

In childhood (causes perisistent infection in most people)

Question 29

Clinical manifestations of H Pylori

Answer 29

* Asymptomatic OR dyspepsia AND/OR epigastric pain * May present with peptic ulcer

Question 30

How does H Pylori infect a patient?

Answer 30

By attaching to the mucosal epithelial cells (stained brown here)

Question 31

5 complications of H Pylori

Answer 31

* Gastric atrophy * Intestinal metaplasia * Peptic ulcer * Gastric cancer (very strong association with the intestinal type of gastric cancer) * Lymphoma

Question 32

Describe the histology of chronic active gastritis secondary to H pylori infection

Answer 32

* "Chronic" = plasma cells in lamina propria * "Active" = neutrophils infiltrating the lamina propria and glands

Question 33

Define autoimmune gastritis

Answer 33

Autoimmune process directed against gastric parietal and chief cells

Question 34

What does autoimmune gastritis lead to?

Answer 34

Chronic inflammation of gastric body with loss of parietal and chief cells --\> Achlorhydria and megaloblastic anemia (secondary to deficient secretion of intrinsic factor)

Question 35

Define a peptic ulcer

Answer 35

Breach in the integrity of the mucosa extending beyond the muscularis mucosae

Question 36

Cause of peptic ulcer

Answer 36

Imbalance between the damaging forces and the defense mechanisms of the mucosa

Question 37

Give the 3 locations of peptic ulcer disease in decreasing order of frequency

Answer 37

1. Duodenum 2. Stomach 3. Esophagus (in the setting of GERD)

Question 38

Define mucosal erosion

Answer 38

Smaller than a peptic ulcer; damage is limited to the mucosa

Question 39

Defense mechanisms to prevent peptic ulcers (4)

Answer 39

* 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)

Question 40

Damaging forces that can lead to peptic ulcer disease (7)

Answer 40

* 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

Question 41

3 macroscopic features of peptic ulcer disease

Answer 41

* 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

Question 42

Most important differential diagnosis for peptic ulcers

Answer 42

Ulcerated tumor (most frequently, an ulcerate adenocarcinoma)

Question 43

Why is the differential diagnosis for peptic ulcers especially important in the stomach?

Answer 43

Duodenal neoplasias are very rare and duodenal ulcers are almost always peptic in nature

Question 44

What does the differential diagnosis for peptic ulcer disease depend on?

Answer 44

Endoscopic features Microscopy

Question 45

Differentiate between the size of a peptic ulcer vs. an ulcerated tumor

Answer 45

PU = usually small (\<2 cm) UT = usually large (\>2 cm)

Question 46

Differentiate between the shape of a peptic ulcer vs. an ulcerated tumor

Answer 46

PU = Round to oval, regular "punched out" borders UT = More irregular in shape

Question 47

Differentiate between the borders of a peptic ulcer vs. an ulcerated tumor

Answer 47

PU = edges at the same level with surrounding mucosa or just slightly elevated UT = elevated, thick borders

Question 48

Differentiate between the base of a peptic ulcer vs. an ulcerated tumor

Answer 48

PU = smooth and clean UT = irregular and necrotic

Question 49

Differentiate between the formation of a peptic ulcer vs. an ulcerated tumor

Answer 49

PU = imbalance between defensive and damaging forces UT = tumor forms in epithelium and grows --\> becomes necrotic and the pus drains/pieces break off