tbl 1 oesophageal pathology Flashcards
Oesophagitis – inflammation of oesophagus, a form of mucosal injury
- Chemical – corrosive acids or alkalis leads to extensive mucosal damage (ulceration and later scarring) e.g. child ingesting battery
o ‘Pill’ oesophagitis – prolonged mucosal contact of a tablet in the oesophagus as it is taken with too little water, causing local ulceration, usually in the elderly e.g. iron tablets, antibiotics like _____________ - Infections – rare in healthy people, particularly in a immunocompromised setting
o Common agents are ___________ etc. - Reflux – most common cause of oesophagitis
o Reflux of gastric contents into the lower oesophagus – leads to heartburn, dysphagia, regurgitation of acidic contents
o Related clinical condition is gastroesophageal reflux disease (GERD) - A competent lower esophageal sphincter (LES) and submucosal glands secreting mucus play protective roles in preventing acid reflux
tetracycline and bisphosphonates; HSV, CMV, candida
Reflux oesophagitis
- Gross and microscopy of reflux oesophagitis – endoscopic and/or histologic evidence of inflammation
o Endoscopy – range of appearances redness to erosions, ulceration or strictures at the lower end of oesophagus (but may be normal-looking)
- Histology
o Increased thickness of the stratified squamous epithelium with ____________ – basal zone represents >20% of squamous epithelial thickness
o Inflammatory cells present intraepithelial eosinophils, lymphocytes
o At a later stage, neutrophils are present, with or without ulceration
o Eosinophilic (“allergic”) oesophagitis – clinical features may be similar to reflux oesophagitis, usually occurs in young individuals and patients with atopic conditions and food allergies
basal zone hyperplasia
Complications of reflux oesophagitis – ulcerations, _________or _______(dark black faeces associated with UGIT bleeding), strictures (fibrous scarring as injury heals) and/or Barrett’s oesophagus when damaged epithelium is replaced with columnar epithelium
haematemasis; melena
Barrett’s oesophagus
- Normal oesophagus epithelial type (stratified squamous) is not protective against acid – repeated damage leads to metaplasia (as an adaptation)
o _________ occurs as stratified squamous becomes columnar epithelium which may resemble the gastric cardia, gastric body or intestinal mucosa
o Intestinal metaplasia – columnar epithelium with intestinal type of epithelium (goblet cells being the defining feature), a defining feature of Barrett’s oesophagus - Change in epithelium of the tubular oesophagus – recognised at endoscopy
o Confirmation of intestinal metaplasia on
biopsy
o Long segment BO – more than 3cm
o Short segment BO – less than 3cm - No clinical features are attributable to Barrett’s oesophagus per se – endoscopy
with histological correlation is required for diagnosis - Complications
o Dysplasia (0.2% to 1% of cases annually) – low grade and high grade –
cytological and architectural aplasia
o Adenocarcinoma (0.5% annually) – for long segment BO, there is a 3 to 125
times risk
§ There is _____ risk of high grade dysplasia - Dysplasia in Barrett’s oesophagus – BO can be negative, positive (high or low
grade) or indefinite for dysplasia - Indefinite – differential between low grade dysplasia or inflammatory reactions
Metaplasia; 30%
Role of biopsy in Barrett’s oesophagus
- Documentation of intestinal metaplasia and detection of dysplasia
o If dysplasia is present, it is graded (low or high) and any abnormal surface seen on endoscopy is biopsied
- Exclude ___________
- Dysplasia is an important marker of cancer risk but most biopsies are negative for dysplasia and most patients never progress to dysplasia or cancer
invasive malignancy
Oesophageal tumours
- The commonest oesophageal tumours are malignant epithelial tumours –
carcinomas (accounting for >90% of malignant tumours)
o Arising from ________ – squamous cell carcinoma
o Arising from ___________ – adenocarcinoma
- Tumours with close relation to the GEJ – guidelines on differentiating oesophageal from gastric tumours
o All carcinomas arising in the tubular oesophagus are staged as oesophageal carcinomas
o Carcinomas involving the GEJ with tumour midpoint ≤____ into the proximal stomach/cardia are considered oesophageal carcinomas - Lymphatics of the oesophagus – extensive lymphatics throughout the oesophageal wall, particularly submucosa and also the mucosa
o Longitudinal nature of submucosal lymphatics can lead to multiple tumour deposits away from the main tumour mass – early dissemination of tumours
o Lymphatics are the earliest mode of spread of tumours
stratified squamous epithelium; metaplastic columnar epithelium; 2 cm
TNM classification – staging of oesophageal tumours
o Primary tumour staging is important – T1 extends into _____, T2 extends into ____________, T3 extends into _______ and T4 extends into adjacent structures such as the aorta, pleura, pericardium, diaphragm
o End-staging is important
– regional lymph nodes assessed for metastasis
e.g. M1 stage shows metastasis in liver
mucosa and submucosa; muscularis propria; adventitia
scc
- location: upper middle third
- common predisposing factors: alcohol, smoking, synergistic
- epidermiology: less developed world, geographic variation
- prognosis: present at advanced stage, poor prognosis
- histology: Invasive carcinoma with squamous differentiation – keratin pearls and _____________
intercellular bridges
adenocarcinoma:
- lower third
- predisposing factors: Barrett’s oesophagus, ________, smoking, obesity
- developed world, more commonly in men
- invasive carcinoma with glandular differentiation- mucin positive
long standing GERD,
where does upper third of oesophagus drains to?
cervical lymph nodes
drainage of middle 1/3 of esophagus?
mediastinal and paratracheal lymph nodes
drainage of lower 1/3 of esophagus?
gastric and coeliac lymph nodes
