10/6- Esophageal Pathology Flashcards Preview

MS2 GI > 10/6- Esophageal Pathology > Flashcards

Flashcards in 10/6- Esophageal Pathology Deck (51)
1

Describe the anatomy of the esophagus

- Length

- Muscle

- Sphincters

- Lyers

- 25 cm long hollow tube (40 cm distance form incisors to GE junction)

- Upper 1/3 = striated muscle; middle third is mixed and lower 1/3 is only smooth muscle

- Upper and lower esophageal sphincters are functional

- Has no serosa; rapid mediastinal spread of invasive lesions

2

What are 3 narrow points in the esophagus?

- What can occur here?

- Upper sphincter

- Behind heart

- Lower sphincter

Can give sensation of an object tin the esophagus

3

Label the layers

4

What is seen here? 

- Brush cell layer

- Lamina propria

5

T/F: The esophagus is surrounded by a rich submucosal venous plexus?

True 

6

What is a hiatal hernia?

- Epidemiology: kids/adults

Separation of the diaphragmatic crura and protrusion of stomach into thorax through the gap

- Congenital hiatal hernias usually in infants and children

- Symptomatic in fewer than 10% of adults; generally associated with other causes of LES incompetence

7

What are symptoms of a hiatal hernia?

- Heartburn and regurgitation of gastric juices

Similar to gastroesophageal reflux disease (GERD)

8

What is infectious esophagitis?

- Important cause of esophagitis, especially in immunocompromised

- Most common acute forms are from viruses and fungi

- Bacterial esophagitis may occur in pts with systemic and upper respiratory infection (rarely biopsied)

9

Describe fungal esophagitis?

- Etiology

- Demographic

- Symptoms

- Most commonly from Candida albicans and Candida tropicalis

- Primarily in pts with underlying disease (may be found in healthy pts)

Symptoms: dysphagia and odynophagia

- Some are asymptomatic; incidental finding at esophagoscopy performed for other reasons (esp in elderly)

10

What is seen here? 

Infectious esophagitis

- White plaques of fibrinopurulent exudate

11

Which is worse, Candida albicans or tropicalis?

- C tropicalis is more virulent than C. albicans

- Increased potential for tissue invasion

12

What is required for diagnosis of Candida esophagitis?

Yeast and psuedohyphae should be detected within tissue

- In immunosuppressed patients: only minimal inflammation

  • Special stains (silver stain, periodic acid–Schiff [PAS]) should be used to detect small numbers of invasive fungal forms

13

T/F: Candida is part of the normal flora of the GIT

True

14

What is a good drug to treat Candida esophagitis?

Fluconazole (Diflucan)

- Safe and well tolerated

(Itraconazole and ketoconazole)

15

What is seen here? 

Candida yeasts within cell layers (not just contamination from oral cavity) 

16

What is seen here? 

17

What can cause viral esophagitis?

- Herpes simplex

- Varicella-zoster

- CMV

- HIV

Most commonly in immunosuppressed patients

- AIDS

- Prior chemotherapy

- Organ transplantation

18

What are symptoms of viral esophagitis?

- Odynophagia

- Dysphagia

- Epigastric pain

- Fever

- Upper GI bleeding

Some are asymptomatic

19

Coexistent ____ is found in 1/4 of patients with viral esophagitis

Coexistent herpes labilais and oropharyngeal ulcers are found in 1/4 of patients with viral esophagitis

20

What is seen with herpetic ulcers in the esophagus?

- It acts as a portal of entry for other pathogens… frequently associated with herpetic pneumonitis

- Endoscopically: shallow and sharply punched out ulcer surrounded by relatively normal-appearing mucosa

21

What is the pathology of herpetic ulcers?

- Characteristic herpetic inclusion bodies are limited to the squamous epithelial cells, margin of ulcer

- Cowdry A intranuclear viral inclusion bodies, ground-glass nuclei, nuclear molding, multinucleated giant cells and ballooning degeneration of infected cells

- Herpes simplex type I is the most common cause of herpetic esophagitis

  • Immunohistochemical staining and in situ hybridization

22

What is seen here? 

Multiple fragments of necro-inflammatory material (ulcer) 

23

What is seen here? 

- Chromatin pattern of a normal lymphocyte

- Ground glass chromatin in cells that are infected by virus

24

What is seen here? 

- Margination of chromatin to the periphery

- Molding of nuclei

- Multinucleation

- Necroinflammatory debris (ulcer)

- Ground glass appearance of nuclei 

25

What is seen here?

HSV immunohistochemical stain

26

What is reflux esophagitis?

- Prevalence

- Causes

- Common chronic condition, esp in Western countries

- Estimated prevalence: 20-40%

- Prolonged and repeated contact of esophageal epithelium with gastric and duodenal contents

  • Pepsin, bile, gastric acid and duodenal content: injury to esophageal mucosa.. inflammation and proliferative response

27

What are predisposing factors to reflux esophagitis?

Decrease lower esophageal sphincter tone

- Alcohol and tobacco use

Increase abdominal pressure

- Obesity

- Hiatal hernia

- Delayed gastric emptying

- Increased gastric volume

Most of the time no definitive cause

28

What is the morphology of reflux esophagitis?

- Endoscopy

- Mild GERD

- More significant disease

Endoscopy

- Erosion, ulcer or stricture

- Hyperemia (redness) or normal mucosa in up to 60% of symptomatic patient

Mild GERD: unremarkable mucosal histology

More significant disease

- Intraepithelial eosinophils and lymphocytes

- Basal zone and papillary hyperplasia

Congestion of small vessels with associated microhemorrhage

29

What is seen here?

Reflux esophagitis

- Hyperemia (redness) in the lower esophagus 

30

What is seen here? 

Reflux esophagitis

- Congestion and microhemorrhage

- Basal cell hyperplasia (darker cells)

31

What is seen here?

32

What is the clinical presentation of reflux esophagitis?

- Demographic

- Symptoms

- More prevalent in adults > 40 yo

Most common clinical symptoms:

- Dysphagia

- Heartburn

- Regurgitation of gastric contents

33

More on reflux esophagitis:

- Treatment

- Complications

Treatment:

- Proton pump inhibitors

- H2 histamine receptor antagonists

- Symptomatic relief

Complications:

- Esophageal ulceration

- Hematemesis

- Melena

- Stricture

- Barrett's esophagus

- Erosive esophagitis is a risk factor for Barrett's (1-13% annually)

34

What is Barrett Intestinal Metaplasia?

Premalignant metaplasia caused by gastroesophageal reflux disease (GERD)

- Squamous epithelium -> metaplastic columnar epithelium (still normal morphology, just in the wrong place)

- Common in general population: 1 – 10%

- 12 – 15% of patients with GERD

- Risk of cancer 30 – 125 times greater than age-matched population

- Risk of adenocarcinoma in Barrett: 0.1-0.5% per year

  • Periodic endoscopic surveillance

(So reflux esophagitis may -> Barrett's intestinal metaplasia, may -> adenocarcinoma)

35

What is seen here? 

Goblet cells

36

What is seen here?

Goblet cells

37

What is seen here? 

Endoscopic lesion in Barrett's esophagus

38

Case)

- 63 yo woman

- Progressive dysphagia

- Biopsy of distal esophagus 

Adenocarcinoma

39

What is seen here?

Esophageal squamous epithelium

40

What is seen here? 

- Basal cell hyperplasia

- Intraepithelial lymphocytes 

41

What is seen here? 

Adenocarcinoma

- Cells with dark nuclei with different shapes/sizes

- Gland formation

42

What are diagnostic procedures for:

- Adenocarcinoma

- Reflux esophagitis

Distal esophagus biopsies

43

Describe esophageal adenocarcinoma

- Incidence

- Etiology

- Predictive factors

- Treatment

- Incidence increased 350% since 1970 (US/Europe)

- Etiology uncertain

- Most cases detected at advanced stage with poor survival

- Preceded by Barrett’s intestinal metaplasia

- Esophagectomy only for either extensive high-grade dysplasia or invasive carcinoma

44

What is seen here?

Low grade dysplasia in adenocarcinoma

45

What is seen here? 

High grade dysplasia in adenocarcinoma

46

Describe squamous cell carcinoma

- Incidence

- Demographics

- Symptoms

- Location

- Used to be the #1 type of esophageal cancer (90-95%) in US before 1970

- Mostly African-American men with long hx of smoking and alcohol

- Worldwide: the most common type of esophageal cancer

- Adults >40 yo

- More in men (4x)

- Presentation: dysphagia and weight loss

- Mostly lethal disease

- Half of the cases: middle third of the esophagus

47

What is seen here?

Mass in esophagus

- This is squamous, but couldn't tell grossly

48

What is seen here?

Normal squamous cell epithelium

49

What is seen here?

Desmoplasia: fibroblast trying to keep tumor from invading??

50

What is treatment and prognosis for squamous cell carcinoma?

Prognosis: poor

Treatment:

- Esophagectomy

- Photodynamic therapy

51

What is photodynamic therapy?

- Photosensitizing chromophores, selectively retained by dysplastic malignant tissue

- Light is delivered in the area where the photons are absorbed by the photosensitizer

- Photosensitizer becomes photoexcited and transfers its energy to a chemical substrate that causes biologic damage to the abnormal tissue