Pathology of the upper GIT Flashcards
What are the different pathologies of the upper GIT?
1) Congenital anomalies
2) Achalasia
3) Hiatal hernia
4) Diverticula
5) Laceration
6) Varices
7) Reflux
8) Barretts
9) Esophagitis
10) Neoplasms (Benign, squamous cell carcinoma, Adenocarcinoma)
What is meant by heart burn?
It is a burning sense of pain in the chest
What is meant by dysphagia?
It is a non-specific terms that denotes a Difficulty in swallowing
What is meant by hematemesis?
The vomiting of blood
What is meant by hemoptosis?
When there is blood in the sputum
What are the different types of obstructive esophageal diseases?
1) Mechanical Obstruction (closed route)
2) Functional Obstruction (problem in the peristalsis)
What are the different forms of mechanical obstruction of the esophagus?
1) Ectopic tissue (gastric, sebaceous, pancreatic)
2) Atresia/Fistula
3) Stenosis/Webs
4) Schiatzki “ring” in the lower esophagus
What is meant by atresia/fistula?
- It is when a thin, non-canalized cord replaces a segment of the esophagus
- It occurs most commonly at the level of the tracheal bifurcation, where a fistula connects the upper or lower esophageal pouches to the bronchus or the trachea
- It can result in aspiration pneumonia, severe suffocation, electrolyte & fluid imbalances
What is meant by stenosis?
It is the narrowing of the esophagus due to inflammation and scarring, which might be due to chronic gastroesophageal reflux, irradiation, or a caustic injury these all will lead to inflammation = healing = narrowing
What is meant by the esophageal rings and webs?
- They are folds that can partially or completely block the esophagus
1) Rings are bands of normal esophageal tissue that forms constrictions around the inside of the esophagus most commonly in the distal esophagus
2) Webs are thin layers of cells that grows across the inside of the esophagus most commonly in the upper esophagus
What are the possible causes of the rings and webs of the esophagus?
1) Iron deficiency anemia
2) Plummer vinson syndrome
What are the various functional obstruction of the esophagus
- Problem in the peristalsis (discoordinated contraction/spasm of the muscularis), like:
1) Achalasia
2) Hiatal Hernia
3) zenker “Diverticulum”
4) Esophagophrenic diverticulum
5) Mallory-Weiss tear
What is meant by achalasia?
- AKA Esophagospasm
- It is an esophageal motility disorder involving the smooth muscle layer of the esophagus (in the absence of other explanations like cancer or fibrosis)
- Achalasia is characterized by a difficulty in swallowing, regurgitation and in some cases chest pain
What is the triad of achalasia?
1) Esophageal aperistalsis (inability of the smooth muscle to move food down the esophagus)
2) Incomplete relaxation of the lower esophageal sphincter
3) Increased Lower esophageal sphincter tone
What are the types of achalsia?
1) Mostly Primary (idiopathic cause)
2) Secondary achalasia in (Chagas disease “kissing bug” bl bed, Diabetic autonomic neuropathy, infiltrative disorders like malignancy, amyloidosis or sarcoidosis)
What is meant by hiatal hernia?
It is the protrusion of the stomach into the thorax due to a defect in the diaphragmatic crura (either the esophageal hiatus is too big or the muscle is too weak)
What are the major types of hiatal hernia?
- In all cases the stomach is above the diaphragm
1) Sliding
- The gastroesophageal junction slides with the stomach above the diaphragm (it is the most common one
2) Paraesophageal
- Only the fundus of the stomach is above the diaphragm
3) Mixed
4) Short esophagus
What are the associated factors with hiatal hernia?
- It increases with age
- Associated with ulceration, bleeding, perforation, strangulation
What is meant by esophageal diverticulum?
- It is an outpouching of the mucosa through the muscular layer of the esophagus
What are the types of esophageal diverticulum?
1) True (the four layers)
2) False diverticulum (the mucosa and submucosa layers)
What are the different locations of esophageal diverticulum?
1) Zenker (high): Posterior outpocketing of the mucosa and submucosa (psudo-diverticulum) through the cricopharyngeal muscle (due to its relaxation and contraction), resulting in an incoordination between the pharyngeal propulsion and cricopharyngeal relaxation (associated with bad breath, and regurgitation of the food)
2) Traction (Mid): Traction (pushing and pulling part of the esophagus) from the mediastinal inflammation
3) Epiphrenic “as it is close to the diaphragm” (Low): due to motor dysfunction (like achalasia, diffuse esophageal spasm)
What is meant by laceration?
- Longitudinal mucosal tears in the lower esophagus
- It is associated with vomiting but not in a normal person as their gastroesophageal muscles relaxes but in alcoholic or prolonged vomiting this muscle relaxation mechanism fails to occur and thus laceration will happen Mallory-Weiss tears
- If the gastroesophageal muscles fails to relax the esophageal wall will tear and patients might present with hematemesis
What are the most vulnerable GIT site to develop varices?
In the junction between the systemic and portal circulation (esophageal, umbilical and hemorroids)
- Any increase in the portal pressure would lead to varices (liver cirrhosis, hepatitis C and B can all increase the portal pressure)
- Massive, sudden, fatal hemorrhage is the most feared consequence
- Varices can be detected using angiography (dilated veins lying within the submucosa of the distal esophagus and proximal stomach)
What is esophagitis?
Inflammation of the esophagus (made of stratified squamous mucosa)
What are the causes of esophagitis?
1) Chemicals
- Alcohol
- Extremely Hot drinks
- Chemotherapy
- LYE (A chemical agent used to suicide)
2) Infectious
- Viruses (HSV, CMV)
- Funguses (especially candida)
3) GERD/Reflux Barrett’s
4) Barrett’s
What is meant by reflux esophagitis/GERD?
- Most commonly in adults over 40 years
- Inflammation of the esophagus due to the reflux of the stomach content to the lower part of the esophagus
What are the risk factors/causes of reflux esophagitis/GERD (gastroesophageal reflux disease)?
1) Decreased lower esophageal sphincter tone
2) Increased abdominal pressure (like pregnancy)
3) Obesity
4) Hiatal hernia
5) Slowed reflux clearing
6) Delayed gastric emptying
7) Alcohol or tobacco use
What is the typical clinical presentation of reflux esophagitis/GERD?
1) Heart burn
2) Chest discomfort/pain
3) Feeling of acidity
4) Excessive salivation
5) Trouble in sleeping
6) Bloating/Gas
7) Regurgitation
What are the Atypical clinical presentation of Gastroesophageal reflux diseases?
1) Cough
2) Chronic sore throat
3) Asthma
4) Difficulty swallowing
5) Bad breath
6) Hoarseness
Describe the mucosal histology in GERD
- The cells of the esophagus are not built for acid content and thus this will cause irritation that will lead to inflammation and then hyperemia and inflammatory cells will accumulate (Eosinophils “first commers”, neutrophils & lymphocytes)
- The basal zone will induce hyperplasia
- The lamina propria papillae will get elongated and congested due to regeneration
What is meant by barrett’s esophagus?
- It is a complication of “chronic” GERD characterized by metaplasia within the esophageal squamous mucosa changing it into the stomach’s epithelium as a form of adaption (metaplastic columnar tissue)
- In barrett’s we have both esophagitis and metaplasia
- Goblet cells are present in the esophageal mucosa (and it is a diagnostic criteria)
- It is the most common risk factor for esophageal adenocarcinoma
Describe the gross picture of barrett’s esophagus
- In barrett’s esophagus the usual pale color of the esophagus will turn into a red, velvety color (the same color as the stomach mucosa) which will extend from the gastroesophageal junction
- This is indicative of metaplastic barretts changes, as we usually diagnose barretts endoscopically
What is the most important thing to look for in barrett’s esophagus?
- Diagnosis requires an endoscopy and a biopsy
- We should look for plastic hyperplasia as most/all adenocarcinoma arising in the esophagus are from previous barrett’s
- Patients should have a regular check-up every 6m-1yr
What are the tumors of the upper GIT?
1) Benign
2) Malignant
What are the malignant tumors of the upper GIT?
1) Squamous cell carcinoma (malignancy without metaplasia)
2) Adenocarcinoma (with metaplasia)
What are the benign tumors of the upper GIT?
1) Leiomyomas
2) Fibrovascular polyps
3) Condylomas (HPV)
4) Lipomas
What squamous cell carcinoma?
- Uncontrolled growth of atypical squamous cells often associated with invasion into the underlying tissues with the potential of metastasis, but their is no metaplasia (no change in the type of cell)
- Most squamous cell carcinomas are moderately to well-differentiated
- If the tumors becomes symptomatic it means that they are very large and that it invaded the esophageal wall
What are the risk factors of squamous cell carcinoma?
1) Tobacco use
2) Alcohol use
3) Nitrates
4) HPV infection
Where does squamous cell carcinoma occur in the esophagus?
50% of the squamous cell carcinoma occurs in the middle third of the esophagus, it starts as dysplasia (change in shape, size, etc) then in-situ lesion then infiltration
What is an adenocarcinoma?
- It is a malignant neoplasm originating in the epithelial tissue with glandular characteristics and has metaplasia (change in the type of cell)
- It typically arises in a background of barrett esophagus and long standing GERD, tobacco and alcohol use are also a risk factor
- It usually occurs in the distal third of the esophagus
How does the cell progress to become an adenocarcinoma?
1) Squamous epithelium
2) Esophagitis
3) Barrett esophagus
4) Dysplasia
5) Adenocarcinoma
Describe the macroscopic picture of adenocarcinoma
It might invade the adjacent gastric cardia, and since it is a adenocarcinoma it is associated with mucus production and forms glands
