10/6- Esophageal Pathology Flashcards
(51 cards)
1
Q
Describe the anatomy of the esophagus
- Length
- Muscle
- Sphincters
- Lyers
A
- 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
Q
What are 3 narrow points in the esophagus?
- What can occur here?
A
- Upper sphincter
- Behind heart
- Lower sphincter
Can give sensation of an object tin the esophagus
3
Q
Label the layers
A
4
Q
What is seen here?
A
- Brush cell layer
- Lamina propria
5
Q
T/F: The esophagus is surrounded by a rich submucosal venous plexus?
A
True
6
Q
What is a hiatal hernia?
- Epidemiology: kids/adults
A
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
Q
What are symptoms of a hiatal hernia?
A
- Heartburn and regurgitation of gastric juices
Similar to gastroesophageal reflux disease (GERD)
8
Q
What is infectious esophagitis?
A
- 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
Q
Describe fungal esophagitis?
- Etiology
- Demographic
- Symptoms
A
- 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
Q
What is seen here?
A
Infectious esophagitis
- White plaques of fibrinopurulent exudate
11
Q
Which is worse, Candida albicans or tropicalis?
A
- C tropicalis is more virulent than C. albicans
- Increased potential for tissue invasion
12
Q
What is required for diagnosis of Candida esophagitis?
A
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
Q
T/F: Candida is part of the normal flora of the GIT
A
True
14
Q
What is a good drug to treat Candida esophagitis?
A
Fluconazole (Diflucan)
- Safe and well tolerated
(Itraconazole and ketoconazole)
15
Q
What is seen here?
A
Candida yeasts within cell layers (not just contamination from oral cavity)
16
Q
What is seen here?
A
17
Q
What can cause viral esophagitis?
A
- Herpes simplex
- Varicella-zoster
- CMV
- HIV
Most commonly in immunosuppressed patients
- AIDS
- Prior chemotherapy
- Organ transplantation
18
Q
What are symptoms of viral esophagitis?
A
- Odynophagia
- Dysphagia
- Epigastric pain
- Fever
- Upper GI bleeding
Some are asymptomatic
19
Q
Coexistent ____ is found in 1/4 of patients with viral esophagitis
A
Coexistent herpes labilais and oropharyngeal ulcers are found in 1/4 of patients with viral esophagitis
20
Q
What is seen with herpetic ulcers in the esophagus?
A
- 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
Q
What is the pathology of herpetic ulcers?
A
- 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
Q
What is seen here?
A
Multiple fragments of necro-inflammatory material (ulcer)
23
Q
What is seen here?
A
- Chromatin pattern of a normal lymphocyte
- Ground glass chromatin in cells that are infected by virus
24
Q
What is seen here?
A
- 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
