Pathology of the Esophagus Flashcards
What are the three layers of the mucosa in the esophagus and what type of epithelium does it have?
- Epithelium - stratified squamous non-keratinized
- Lamina propria - connective tissue with minimal mononuclear inflammatory infiltrate
- Muscularis mucosae - longitudinally oriented smooth muscle bundles becoming thicker in distal esophagus
What is the characteristic prengnancy finding for a tracheo-esophageal fistula and what is the most common type?
Characteristic finding - polyhydramnios (can’t swallow)
Most common type: Esophageal atresia with distal tracheo-esophageal fistula
What is a pulsion diverticulum and what are the two main types? Is it a true diverticulum?
Mucosal herniation (pseudodiverticulum since not the whole wall) caused by high intraluminal pressures
- Zenker diverticulum - most common
- Epiphrenic diverticulum
Where does Zenker diverticulum occur and what are the symptoms?
Occurs posteriorly between cricopharyngeus and inferior constrictor muscles
-> retention of food and secretions in pouch
Symptoms: oropharyngeal dysphagia, regurgitation of undigested food, bad breath from food, aspiration
What is an epiphrenic diverticulum and how does it arise typically?
A pulsion diverticulum of the distal esophagus just above the LES, usually associated with esophageal dismotility disorders (achalasia, hiatal hernia)
What is a traction diverticulum and what causes it?
A mid-esophageal diverticulum caused by something pulling on the esophagus
Commonly due to malignancy or TB with scarring
Who tends to get esophageal webs and what are they associated with?
Middle aged women
Associated with GERD, chronic graft-versus host disease (esophagitis will predispose), and blistering skin diseases (??)
What are esophageal webs? How are they different than rings?
Webs - Idiopathic, partially circumferential membranous thickenings in upper esophagus, cause intermittent obstruction and dysphagia
Rings - idiopathic, same as webs just slightly thicker and extend for the entire circumference
What characterizes Plummer Vinson syndrome?
Iron deficiency anemia, esophageal webs, dysphagia
Also: glossitis, cheilosis, koilonychia, and increased risk for pharyngeal and esophageal carcinoma
What are the two types of esophageal rings? When do they happen?
A ring - found proximal to GE junction, covered with squamous epithelium
B ring / Schatzki ring - occurs AT GE junction, often superiorly covered with squamous epithelium and inferiorly covered with glandular epithelium. Happens in association with hiatal hernia
What is an esophageal stricture and what is it most associated with?
Luminal narrowing due to inflammation / fibrosis of esophagus
Due to:
1. Chronic GERD
- Ingestion of caustic materials (i.e. lye)
What forms the esophageal hiatus? What components prevent gastroesophageal reflux?
Diaphragmatic crura
Reflux prevented by:
1. Diaphragmatic crura
- LES pressure, benefited by its intraabdominal location, pushing the stomach closed
- Angle of his - acute angle between distal esophagus and gastric cardia
What are the risk factors for diaphragmatic hernia?
- Decreased LES tone / elasticity - due to advanced age
2. Increased intraabdominal pressure above what’s good - obesity, pregnancy, ascites
What are the two types of diaphragmatic hernias and which is most common?
- Sliding hiatal hernia - GE junction slides into mediastinum, giving hourglass appearance - most common
- Paraesophageal / rolling hiatal hernia - fundus of stomach prolapses into thorax adjacent to GE junction
What are the risks associated with sliding and rolling hiatal hernias?
Sliding - Increased risk of GERD due to loss of angle of His and LES tone
Rolling - strangulation and perforation of involved fundic stomach (compromising blood flow)
What are the two esophageal syndromes associated with violent wretching and which is more serious? why?
- Mallory-Weiss syndrome - partial-thickness longitudinal mucosal lacerations at GE junction
- Boerhaave syndrome - transmural, distal rupture due to violent wretching -> can cause mediastinitis and subcutaneous emphysema (due to air in mediastinum) and is a surgical emergency
What causes esophageal varices and why do they ultimately rupture?
Portal hypertension -> overtime the epithelium overlying them breaks down due to trauma -> erosion causes rupture
Massive hematemesis has high morbidity / mortality
What are some causes of esophagitis due to ingested chemicals? What is the pathogenesis of this?
Various irritants -> mucosal ulceration and necrosis -> acute inflammation and fibrosis
i.e. pills causing irritation, caustic ingestion, or acid ingestion
What is iatrogenic esophagitis?
Most often due to radiation or graft-versus-host disease -> something the doctors did predisposes to esophagitis
What are the three causes of infectious esophagitis and who generally gets it? Give the morphology for each.
Generally immunocompromised individuals
- Candida - white pseudomembranes
- HSV-1 - punched out ulcers
- CMV - linear ulcers from base of esophagus
What are the risk factors for GERD / Reflux Esophagitis?
Same as sliding hiatal hernias
-> things that decrease sphincter tone or increase intraabdominal pressure
i.e. hiatal hernia, obesity/pregnancy, delayed gastric emptying (increased pressure and acidic stomach pH)
only thing not explained: alcohol and tobacco use -> they are irritants
What does reflux esophagitis look like grossly and microscopically?
Grossly - Mild hyperemia, can’t tell much
Microscopically - Intraepithelial eosinophils (first infiltrate seen in GI inflammation), later neutrophils, and bazal zone hyperplasia with elongation of lamina propria papillae
What are the symptoms of GERD?
Dysphagia, heartburn, waterbrash (tasting acid in your mouth), chest pain in adults
What are the complications of GERD?
- Stricture formation
- Barrett esophagus
- Erosion / ulceration of esophagus with possible bleed (Rare)
What is Barrett esophagus? How does it appear grossly?How is it told apart from glandular stomach epithelium?
Glandular intestinal metaplasia of distal esophagus due to longstanding GERD
Appears as patchy red spots wherever the glandular epithelial metaplasia is
-> told apart from stomach epithelium by presence of Goblet cells
What are the complications of Barrett esophagus? How do you track this?
Track this by periodic endoscopy and biopsy
- Epithelial dysplasia - low or high grade
- Adenocarcinoma - intramucosal and invasive
What type of esophageal carcinoma is most common in the US and what is its presentation?
Adenocarcinoma - progression from Barrett esophagus
Progressive dysphagia for solids then liquids, progressive weight loss
What type of esophageal carcinoma is most common in the rest of the world and what are its risk factors? Where does it arise?
Squamous cell carcinoma, arises usually mid-esophagus but can be anywhere
RF: alcohol and tobacco smoking**, hot liquids and achalasia (irritation), caustic strictures with repeated injuries, Plummer-Vinson, etc
Where does squamous cell carcinoma spread?
Locally extends to other mediastinal organs, even aorta causing a massive bleed
Can also infiltrate lymphatics and spread hematogenously
How does squamous cell carcinoma of the esophagus appear grossly and microscopically?
Grossly: Mucosal plaque becomes exophytic, ulcerative, or diffusely infiltrative and gray-white. May form a stricture
Microscopically - Nests of large, polygonal, eosinophilic cells +/- keratinization depending on degree of differentiation
How does adenocarcinoma of the esophagus appear grossly and microscopically?
Grossly - Irregular mucosal plaque which can become nodular, ulcerative, or diffusely infiltrative
Microscopically - adenocarcinoma arising amongst Barrett esophagus
