CP11-1 Upper GI Pathology

Question 1

What are 3 main pathologies affecting the oesophagus?

Answer 1

Oesophagitis and gastro-oesophageal reflux
Barrett’s oesophagus
Oesophageal carcinoma

Question 2

What are 3 pathologies affecting the stomach?

Answer 2

Acute and chronic gastritis
Peptic ulceration
Gastric carcinoma

Question 3

What is an example of a pathology affecting the small bowel?

Answer 3

Coeliac disease

Question 4

What cells make up the oesophagus?

Answer 4

Mainly stratified squamous epithelium until the distal portion around the level of the diaphragm where the cells become squamocolumnar (squamocolumnar junction) before becoming normal columnar epithelium of the stomach lining

Question 5

What is oesophagitis?

Answer 5

Inflammation of the oesophagus. Can be acute or chronic.

Question 6

What causes oesophagitis?

Answer 6

Usually viral e.g. HSV or CMV, or fungal like candida
Can also be chemical via ingestion of corrosive substances or due to reflux of gastric contents.

Question 7

What is reflux oesophagitis?

Answer 7

Inflammation of the oesophagus due to reflux of gastric acid or bile.

Question 8

What are risk factors for reflux oesophagitis?

Answer 8

Defective lower oesophageal sphincter
Hiatus hernia
Increased intra-abdominal pressure e.g. from pregnancy
Increased gastric fluid volume due to outflow stenosis.

Question 9

What is the main symptom of reflux oesophagitis?

Answer 9

‘Heartburn’

Question 10

How does reflux oesophagitis affect the histology of the oesophagus?

Answer 10

Basal cell hyperplasia
Elongation of papillae
Increase cell desquamation
Inflammation
Ulceration if severe

Question 11

What are some complications of reflux oesophagitis?

Answer 11

Ulceration
Haemorrhage
perforation
Bengin stricture (segmental narrowing)
Barrett’s oesophagus

Question 12

What is Barrett’s oesophagus?

Answer 12

Metaplastic transition of epithelium, to columnar mucosa (like in intestines with goblet cells) from stratified squamous, in the oesophagus due to longstanding gastro-oesophageal reflux

Question 13

What are risk factors for Barrett’s oesophagus?

Answer 13

Male
Caucasian
Overweight

Question 14

How does the oesophageal epithelium look under the microscope and histological with Barrett’s oesophagus?

Answer 14

Proximal extension of the squamocolumnar junction with the squamous mucosa replaced by columnar mucosa- glandular metaplasia

Question 15

What does Barrett’s oesophagus increase risk of?

Answer 15

Adenocarcinoma

Question 16

How does Barrett’s oesophagus progress to an adenocarcinoma?

Answer 16

Barrett’s oesopagus —> low grade dysplasia —> high grade dysplasia xx> adenocarcinoma

Question 17

How are patients with Barrett’s oesophagus monitored for neoplasia?

Answer 17

Via regular endoscopic surveillance

Question 18

What are the two main types of oesophageal carcinoma?

Answer 18

Squamous cell carcinomas
Adenocarcinomas

Question 19

What is the epidemiology of oesophageal carcinoma?

Answer 19

8th most common cancer globally
30% of oesophageal carcinomas are squamous in the UK

Question 20

Who is most likely to get an oesophageal adenocarcinoma? Males or females?

Answer 20

Males

Question 21

What causes oesophageal adenocarcinomas?

Answer 21

Barrett’s oesophagus

Question 22

What are risk factors for oesophageal SCC?

Answer 22

Tobacco and alcohol
Nutrition
Thermal injury e.g. hot drinks
HPV infection
Male
Ethnicity = black

Question 23

What part of the oesophagus doe SCC usually develop?

Answer 23

In middle and lower third of the oesophagus (less than 15% in upper third)

Question 24

How can an oesophageal SCC look macroscopically?

Answer 24

Polypodial
With structuring
Ulceration

Question 25

What system is used to stage GI cancers?

Answer 25

TNM staging ( T = primary Tumour staging, N = lymph Node staging, M= distant Metastases)

Question 26

What is the pathogenesis of gastritis?

Answer 26

Increased acid in the stomach causes impaired defences e.g. ischaemia, shock, delayed emptying, duodenal reflux or impaired regulation of pepsin secretion.

Question 27

What can cause increased acid in the stomach disrupting the balance between aggressive and defensive forces of the stomach?

Answer 27

Excessive alcohol Drugs Heavy smoking Ingestion of corrosive substances Radiation Chemotherapy Infection e.g. h.pylori

Question 28

What is the cause of acute gastritis?

Answer 28

Usually chemical injury e.g through NSAIDs or alcohol Initial response to H. Pylori infection

Question 29

What can Acute gastritis cause for the stomach?

Answer 29

Erosions Haemorrhage

Question 30

How soon does acute gastritis heal?

Answer 30

Quickly

Question 31

What causes chronic gastritis?

Answer 31

Autoimmune problems e.g. due to anti-parietal and anti-intrinsic antibodies Bacterial infection e.g. h. Pylori Sustained chemical injury due to NSAIDs, bile reflux potentially alcoholism, causing direct injury

Question 32

What can h. Pylori lead to in chronic gastritis?

Answer 32

Gastric ulcers (in 2-5%) Duodenal ulcers (in 10-15%) Gastric cancer and MALT lymphoma

Question 33

What is h.pylori?

Question 34

What is peptic ulcer disease?

Answer 34

Localised defect/ ulceration of the stomach extending at least into the submucosa.

Question 35

Where are common sites of peptic ulcer disease?

Answer 35

First part of duodenum Junction of antra, and body mucosa Distal oesophagus

Question 36

What causes peptic ulcer disease?

Answer 36

Hyperacidity H. Pylori infection Duodeno-gastric reflux Drugs (NSAIDs) Smoking

Question 37

How do gastric ulcers and duodenal ulcer differ?

Question 38

What are come complications of peptic ulcers?

Question 39

What is the most common gastric cancer?

Answer 39

Adenocarcinomas

Question 40

What are some less common gastric cancers?

Answer 40

Endocrine tumours Lymphomas Stromal tumours

Question 41

What increases risk of adenocarcinoma of gastro-oesophageal junction?

Answer 41

Being a white make Have gastrooesophafeal reflux Incidence increasing reccentky

Question 42

What increases risk of developing an adenocarcinoma in the body/antrum of the stomach?

Answer 42

H.pylori infection Diet high in salt and low in fruit and veg Decreased incidence recently

Question 43

What is the epidemiology of gastric adenocarcinomas?

Answer 43

5th most common cancer globally, 17th in UK accounting for 2% of all new cancer cases Steady decline over past decades

Question 44

What is the aetiology of gastric adenocarcinomas?

Answer 44

Diet - high in smoked/cured meat or fish and pickled by vegetables H. Pylori infection Bile reflux Hydrochlorhydria Genetics (~1% of cases) Gastric ulcers

Question 45

What are the macroscopic subtypes of gastric adenocarcinomas?

Answer 45

Superficial exophytic Flat or depressed Superficial excavated Exophytic Linitis plastics Excavated Polypodial Ulcerated

Question 46

What are the microscopic subtypes of gastric cancer?

Answer 46

Intestinal = well or moderately differentiated, may undergo intestinal metaplasia and adenoma steps Diffuse type = poorly differentiated, scattered growth, associated with cadherin loss/mutation, can be hereditary

Question 47

What percentage of gastric adenocarcinomas are caused by a germline mutation in E-cadherin?

Answer 47

Around 1%

Question 48

What is coeliac disease?

Answer 48

An immune mediated enteropathy which is triggered by ingestion of gluten containing cereals in genetically predisposed individuals

Question 49

What is the epidemiology of coeliac disease?

Answer 49

0.5-1% of people in UK Commonly affects adults between 30-60

Question 50

What is the pathogenesis of coeliac disease?

Answer 50

Reaction to gliadin inducing epithelial cells to express IL-15. Increased production of IL-15 causes activation and proliferation of CD8+ intraepithelial lymphocytes which are cytotoxic and kill enterocytes. CD8+ intraepethial lymphocytes do NOT recognise gliadin directly

Question 51

How is coeliac disease diagnosed?

Answer 51

With non-invasive serologic tests performed before biopsy e.g. IgA antibodies to TTG, IgA or IgG antibodies to delaminated gliadin and anti-endomysial antibodies Tissue biopsy is diagnostic

Question 52

How is coeliac disease treated?

Answer 52

With gluten free diet

Question 53

What are long term complication of coeliac disease if it’s not treated?

Answer 53

Anemia Female infertility Osteoporosis Cancer - enteropathy associated T-cell lymphoma and small intestinal adenocarcinomas

Question 54

What are some diseases associated with coeliac disease?

Answer 54

Dermatitis herpetiformis in 10% of patients Lymohocytic gastritis and colitis

Question 55

If a patient with coeliac disease still gets symptoms when adhering to a gluten free diet, what might they have?

Answer 55

Cancer

Question 56

How does the intestine present histologically with coeliac disease?

Answer 56

Vilous atrophy Crypt elongation Increased IELs Increased lamina propria inflammation

Question 57

What are enterocytes?

Answer 57

Intestinal cells involved in absorption of nutrients