Pathology of the mouth, oesophagus and stomach Flashcards
Oral cancer epidiemiology
1% of all cancers
Types of oral cancer
Squamous cell carcinoma 95% Melanoma Adenocarcinoma
Risk factors for oral cancer
Alcohol, smoking & chewing tobacco >men rare in younger
Examination of the mouth
mouth ulcer that does not heal within 2-3 weeks should be examined by a health care professional
Treatment of oral cancer
-build up strength -speech therapy -relearn eating
Anatomy of the oesophagus
-muscular tube -25cm -posterior to the trachea Course -laryngopharnx - anterior aspect of the neck - enters mediastinum Two sphincters Upper- skeletal muscle lower –> smooth muscle
Histology of the oesophagus
Mucosa (non keratinised squamous epithelium) Lamina propria Skeletal muscle - CILO - upper 1/3 - skeletal -middle 1/3 mixed -lower 1/3 smooth Adventitia
Oesophageal infections
Candida oesophagitis Herpes simplex virus
Candida oesophagitis
Active chronic inflammation due to candida albicans Many neutrophils esp near the superficial surface of the epithelium Staining using a PAS stain confirms the spores and hyphae Common in immunocompromised
Herpes simplex virus
Causes inflammatory exudate with cells (slough) Visible atypical squamous cells (clear cytoplasm) Immunohistochemistry with an antibody can reveal the HSV infection - common in immunocompromised
Oesophagus inflammation - chemicals
Peptic oesophagitis/ GORD Causitics - lye (NaOH, causitic soda) Pills sticking e.g iron (can cause ulceration)
Eosinophillic oesophagitis
Characterised by - eosinophills infiltrating epithelium - allergic - responsive to steroids - endoscoopic like rings :trachealization LOTS OF EOSINOPHILS - dietary sensitizer, fluticasone
Oesophageal cancers: presentation and types
Late presentation (T3 stage) High lethality Dysphagia for solids, then liquids Weight loss Pain and dyspepsia Haematemesis and melaena Two types: - squamous carcinoma - associated with smoking and drinking -adenocarcinoma - obesity and gord
OG junction
Squamous collumnar junction Cancer at this junction is increasing: short segment of barrets oesophagus or association with gastric pathology
What classification is used to classify gastric, oesophagus and junctional cancers?
Siewarts classification above –> 1 at–> 2 Below –> 3
Gastro-oesophageal reflux disease definition
retrograde passage of gastric contents into the oesophagus causing troublesome symptoms (>2 heartburn episodes/wk) and/ or cpmplications
Symptoms of GORD
due to reflux being sufficient to impair quality of life:
Oesophageal
- heartburn (burning, retrosternal discomfort after meals, lying, stooping relieved by antacids)
- epigastric pain
- waterbrush (mouth fills up with saliva)
- odynophadia (painful swallowing, eg from oesophagitis or ulceration)
Extra-oesophageal
- non cardiac chest pain
- wheeze- nocturnal asthma
- chronic cough
- laryngitis
Pattern of GORD
Oesophagitis: inflammation of squamous epithelium secondary to acid damage can cause strictures to Barrets oesophagus: metaplasia of squamous to collumnar caused by chronic acid damage to adenocarcinma - accumulating cellular genetic changes causing dysplasia and ultimately cancer
Causes of GORD
- Lower oesophageal sphincter hypotension
- hiatus hernia
- loss of peristaltic funciton
- abdominal obesity
- gastric acid hypersecretion
- smoking and alcohol
- pregnancy
Seattle protocol
estimate dysplasia four biopsies every 2cm
Investigations of GORD
- endoscopy if symptoms >4 weeks
- persistent vomitting
- GI bleeding/ iron deficiency
- palpable mass
- age >55
- dysphagia
- symptoms despite treatment
- Barium swallow - hiatus hernia
- 24 hr oesophageal pH monitoring + manometry help diagnose GORD when endoscopy is normal
Under the age 45 < symptoms are relatively common and can be treaed empirically. Investigation only if fails to repsond to treatment
Over the age of 45 - reflux can be confirmed by 24h continuous pH monitoring. Peaks of pH change must correspond to symptoms. OGD should be perfomed in all new cases to rule out oesophageal malignancy
Treatment of GORD
- Encourgage- raising the bed head + weight loss, smoking cessation, small regular emals
- Avoid- hot drinks, alcohol, citrus fruits, tomatoes, onions, fizzy drinks, drugs affecting LE motility (nitrates, cholinergics, Ca2+ channel blockers - relax the LES) or that damage the mucosa (NSAIDs, bisphosphonates)
- Drugs - antacids e.g magneisum trisilicate (10ml/8h) or Gaviscon advance relieve symptoms), for oesophatitis (PPI - lansoprazole 30mg/24hr)
- Surgery - aims to increase resting lower oesophageal spincter pressure, consider in severe GORD (confirm by PH-monitoring/manometry) if drugs are not working. Atypical symptoms (cough, laryngitis) are less likely to improve with surgery compared to patients with typical symptoms - Nissen fundoplication
Recognizing dysplasia
“reactive changes, inflammation” none - indefinte for dysplasia mild to moderate - low grade (nuclei stratified, cells polarise) severe- high grade(polarity lost no prominent nucleloi)
Gastritis causes
acute - alcohol, NSAIDs, severe trauma (burns, surgery) Chronic - (ABC) - autoimmune, bacterial, chemical
Acute gastritis
Acute inflammation reaction at the superficial mucose, with infiltration of neutrophils Patho: causitive agents inhibit PGs (portect gastric mucosa) - damage ranges from erosions- ulcers
Autoimmune atrophic gastritis
autoimmune destruction of parietal cells 1. IF needed to absorb vitamin B12 secreted by parietal cells 2. In terminal ileum Cubulin is the receptor for B12-IF complex 3. Amnionless then mediates endocytosis and B12 absorption In absence developses macrocytic anaemia Caused by malabsoprtion of vitamin b12 anti-parietal cell antibodies in blood Eventual complete loss of parietal cells from gastric mucosa with pseudopyloric and intestinal metaplasia persistent inflammation promotes epithelial dysplasia and cancer
Zollinger-Ellison syndrome
Hypersecretion of gastrin by an endocrine tumour in pancreas or DD Leading to increased gastric acid ouptu and florid peptic ulceration
Helicobacter Pylori gastritis
Spiral flagellae, gram negatie, microareophillic bacterium Produces urease Diseases associatedL -gastritis -DU -GU -gastric adenocarcinom and gastry lymphoma Methods of detection - rapid urease test at endoscopy -Histology -Culuture (useful for sensitivity to antbiotics -urea breath test -serology Eradicate with triple therapy e.g omeprazole, metrnoidazole and clarithromycin
Chemical gastritis
Characteristic morphology -few inflammatory cells -surface congestion oedema, elongation of gastric pits, tortosity, reactive hyperplasia/atypia, ulceration Antrum more than corpus Bile reflux, NSAIDs, ehtanol, oral iorn are typical causes
Gastric cancer
historically distal > proximal strongly associated with chronic gastritis: typically H pylori or autoimmune Background of atrophic mucosa with chronic inflammation, intestinal metaplasia, dysplasia Dysplasia may be flat or adenoma-like Intestinal versus diffuse types Proximal versus distal- distinct epidiemoiology
Complications of GORD
- oesophagitis, ulcers, benign stricture, IDA
- Gord may induce barrats oesophagus
- 0.6-1.6%/yr of those with low grade - progress to cancer
- aspiration pneumonia
- upper GI bleeding
Hiatus hernia definition
The presence of part or all of the stomach within the thoracic cavity, usually by protrusion through the oesophageal hiatus in the diaphragm
Clinical features
- common: 30% of patietns >50y, especially obese women
- 50% have GORD
Types of Hiatus hernia
- Sliding hiatus hernia 80%- is where the GOJ slides up into the vhest- acid reflux often happens as the LES become less competent
- Rolling hiatus hernia 20% - is where the GOJ remain in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus.. As GOJ remains intact, gross acid reflux is uncommon
Diagnosis of hiatus hernia
- Upper Gi endoscopy - to exclude oeosphageal mucosal pathology
- Video barum swallow - extent and type - best choice
- CT scanning of the thorac- investigation of choice in acute presentations
Treatment of hiatus hernia
-
Medical
- reduce acid consumption- stop smoking, lose weight, reduce alcohol consumption
- counteract acid secretion- PPIs, symptomatic relief with antacids
- promote oeosphageal and gastric emptying - promotilants e.g metoclopramide
-
Surgical
- rare
- indicated for - persistant symptoms despite max med therapy, established complications of rolling hernia such as volvulus or obstruction
