Pathology Of Upper GI Tract Flashcards
Epithelial of Esopahgus vs. Stomach
Esophagus - stratified squamous non-keratinized epithelia
Stomach - columnar mucosa
What is a hernia?
An abnormal protrusion of tissue/organ through the wall of the cavity in which it resides
Hiatal Hernia
Abnormal protrusion of a segment of the stomach above the diaphragm (hiatus is the opening of the diaphragm through which the esophagus passes)
What are the two types of Hiatal Hernias?
% of each and description
Sliding Hiatal hernia
- 95% of hiatal hernias, has a bell shaped dilation
Nonaxial (paraesophageal) Hiatal hernia
5% of Hiatal Hernias, usually along the greater curvature
What is the significance of Hiatal Hernias?
- commonality
- symptoms
- complications
Common - 1-20% of adults have them (children as well)
Usually asymptomatic - only 9% with sliding hernias have heartburn or regurgitation of gastric juice into mouth
Complications
- ulceration
- bleeding
- perforation
- strangulation of paraesophageal hernias
Achalasia of the Esophagus
Description
Causes
Function disorder of the esophagus characterized by increased resting tone and incomplete relaxation of the lower esophageal sphincter preventing food from entering the stomach
Primary (unknown cause)
Secondary
- Chana’s disease (trypanosoma Cruzi)
- malignancy
- sarcoidosis
Radiologically - bird beak design
Esophagitis
Definition
Causes
Inflammation and epithelial damage of the esophagus
Inflammation can be caused by:
- infection, irritant or autoimmune
Causes of esophagitis:
- gastroesophageal reflux
- infection (uncommon unless immunocompromised)
- eosinophilic esophagitis (males 20-40)
- other
Eosinophilic Esophagitis
Definition
How does it present?
- type of esophagitis characterized by numerous eosinophils within the squamous mucosa associated with dysphagia
- presents as:
1) dysphagia (difficulty swallowing, food impact ion, heartburn)
2) more common in males; affects both children and adults
3) endoscopy: ring appearance (like trachea)
4) Biopsy required to confirm presence of eosinophils
5) Need to exclude GERD
GERD
Definition
Symptoms
Gastric contents leak backwards into esophagus causing irritation/inflammation of esophagus
Symptoms
- variable heartburn
- water brash
- frequent belching
Factors contributing to GERD
- low resting tone in LES
- delayed esophageal clearance
- delayed gastric emptying
- increased abdominal pressure
- increased acid production
How is GERD Diagnosed?
Clinical - history and relief with medication (PPI)
Endoscopy if:
- heartburn with alarm features (bleeding, weight loss)
- persistent reflux or previous severe erosive esophagitis
- Hx of esophageal stricture with persistent dysphagia
Complications associated with GERD
Stricture (scarring)
Ulceration
Bleeding
Barrett Esophagus
Adenocarcinoma
What does a biopsy of GERD show?
1) increasing inflammatory cells in epithelial layer (eosinophils, neutrophils, excess T cells)
2) basal cell hyperplasia exceeding 15-20% of epithelial thickness
3) elongation of lamina propria papillae extending into upper 1/3 of epithelium
How is GERD treated?
PPI
Antacids
Diet modification
Weight loss
Barrett Esophagus
Definition
Significance
How is it diagnosed?
Distal squamous mucosa of esophagus replaced by meta plastic columnar epithelium in response to prolonged injury (columnar epithelium may be more resistant to acid)
- risk for dysplasia and subsequent esophageal adenocarcinoma
- diagnosed via endoscopic and histologic features (biopsy)
Endoscopic features of BE
Red velvety GI type mucosa b/w pale squamous mucosa
- tongues extending up from GEJ or broad band displacing the GE junction proximally
Histologic features of BE
- squamous epithelium replaced by columnar epithelium of intestinal type (small bowel or colon)
- other types of glandular epithelium
- cardiac type epithelium with mucosal distortion, glandular atrophy, mild inflammation
Assessment of BE
-two segment types of BE
Long-segment - Barrett mucosa extending 3cm or more from GE jxn
Short-segment - Barrett mucosa extends <3cm from GE jxn
How is BE treated?
Anti-reflux therapy
Endoscopy every 1-2 years to detect dysplasia, carcinoma (4 quadrant biopsies at intervals of 2cm or less throughout the length of the Barrett’s segment plus any suspicious lesions
Postulated pathway of Dysplasia from BE
Esophagitis —> BE without dysplasia —> low grade dysplasia —> high grade dysplasia —> invasive adenocarcinoma
What is dysplasia arising in BE?
Dysplasia epithelium that does not invade lamina propria (premalignant)
Usually patchy or irregular and may appear endoscopically as thickened, or a polyploid mass
Dysplasia is assessed as low or high grade based on histologic assessment of biopsies
Esophageal carcinoma
A malignant neoplasm of the esophagus
Two types:
1) squamous cell carcinoma (upper 2/3 of esophagus)
2) adenocarcinoma (distal 1/3 of esophagus)
Squamous cell carcinoma
In upper 2/3 of esophagus
Most common world wide
Risk factors are tobacco and alcohol
Adenocarcinoma of esophagus
Distal 1/3 of esophagus
Common in western countries
Risk factor - Barrett esophagus
Gastritis
Inflammation/irritation of the gastric mucosa
Has many causes
How is gastritis classified
Several different classification schemes
Most take into account the acuity of the presentation and histologic features
Acute Gastritis
Definition
Causes
Sudden onset of inflammation and related symptoms often with erosions or ulcer - rarely biopsied
Causes:
- NSAIDs, alcohol, acid, cocaine
- stress, trauma, burns, critically ill, shock, sepsis
- severely debilitated patients
Chronic gastritis
- definition
- types
Ongoing irritation/inflammation of the stomach due to several causes - some have acute inflammation as well
Chronic active gastritis (helicobacter)
Chronic autoimmune gastritis
Reactive gastropathy
Specific forms of gastritis
Chronic Active Gastritis
- defitinition
- significance
Persistent inflammation of the gastric mucosa with varying degrees of acute inflammation
- related to helicobacter infection
- typically affects antrum - may extend to the body
- increased risk of gastric carcinoma and gastric lymphoma
Tests for Helicobacter
Non-invasive:
- Serology
- Urea breath test
- Stool antigen test
Invasive (require endoscopy)
- Histology
- rapid urease test (on biopsy)
- microbiology culture
Chronic reactive gastropathy
Defitinion
Causes
Chronic irritation (usually with minimal inflammation) of the gastric mucosa due to irritant
Causes:
NSAIDs
Bile reflux (prior surgery)
Chronic EtOH
Peptic ulcer disease
What is it
Complications associated with
Acid induced ulceration of the mucosa and wall of the stomach and/or duodenum often associated with H pylori
Complications
- perforation
- hemorrhage
- obstruction (stenosis)
- penetration
Difference between ulcers and erosion
Ulcers extend through full thickness of mucosa
Erosion is limited to the superficial mucosa
Gastric Polyps
- definition
- types
A polyp is an abnormal growth of tissue projecting from a mucous membrane (gastric polyps in stomach)
Neoplastic (benign (adenoma) or malignant)
Non-neoplastic
- hyperplastic polyp
- Fundic gland polyp
Gastric neoplasms
- what are they
- types of malignant neoplasms
An abnormal growth of tissue in the stomach caused by rapid division of cells that have undergone some form of mutation
- may be benign, pre-malignant or malignant
- carcinoma (adenocarcinoma) or lymphomas
Gastric carcinoma
A malignant neoplasm of the gastric epithelium
- more common in certain countries (Japan) - smoked fish
Decreased incidence in North America
Are Adenocarcinomas
Have a poor prognosis
Pre-disposing conditions of Gastric adenocarcinoma
H. Pylori infection
Chronic strophic gastritis with intestinal metaplasia
Post gastectomy
Gastric adenomatous polyps
Endoscopic and histologic appearance of gastric carcinomas
Different endoscopic appearance:
- exophytic, ulcerating, diffuse infiltrating
Histologic:
- intestinal type, and diffuse type (signet ring cell type)
Lymphoma of stomach
In the setting of chronic H. Pylori (MALT lymphoma)
- GI tract is most common site of extranodal lymphoma
- stomach is a relatively common site
- primary
- secondary
