Esophagus

Question 1

Layers

Answer 1

Mucosa (inner) –> submucosa –> musclaris propria –> serosa/adventitia

These are important in cancer staging

Question 2

Cell types of esophagus

Answer 2

Lined by SQUAMOUS MUCOSA (flat epithelium)

Stomach, SI, Colon –> SIMPLE COLUMNAR (elongated, basal nuclei)

Question 3

3 most common causes of infectious esophagitis?

Answer 3

HERPES
CMV
CANDIDIASIS

More common in immunocompromised

Question 4

Herpes Esophagitis

Answer 4

Multiple shallow ulcerations on the DISTAL esophagus

Histo –> cellular debris, neutrophils, GIANT CELLS, ground glass nuclei, necrosis

GIANT CELLS usually enough to indicate herpes esophagitis

Question 5

CMV Esophagitis

Answer 5

Distinguished by a SINGLE, DEEP ULCER

Intranuclear or Intracytoplasmic inclusions in large endothelial and fibroblas cells; some cells may have one or two nuclei

Question 6

Fungal Esophagitis

Answer 6

White-yellow plaques with mucosal ulceration

Histo –> necrotic inflammation with neutrophils and NO MULTINUCLEATED GIANT CELLS and NO INTRANUCLEAR INCLUSIONS

See fungal pseudohyphae/budding yeasts on silver stain

Question 7

Reflux Esophagitis

Answer 7

Presents with DYSPHAGIA, HEARTBURN

Due to BACKFLOW/REFLUX of the gastric contents into the LOWER ESOPHAGUS

Happens most in hiatal hernias, but also with alcoholism, scleroderma, recurrent vomiting

MOST FREQUENT CAUSE OF ESOPHAGITIS

Associated with GERD

Basal Cell Hyperplasia + Eosinophils + Lymphocytes = REFLUX ESOPHAGITIS

Can develop into Barrett Esophagus

Question 8

Eosinophilic Esophagitis

Answer 8

Presents like GERD

HALLMARK is that there is a LARGE # OF INTRAEPITHELIAL SUPERFICIAL EOSINOPHILS

Difference from GERD is that there will be plenty of eosinophils both PROXIMALLY and DISTALLY

In GERD, ONLY Distal inflammation

Question 9

Barrett’s Esophagus

Answer 9

Complication from CHRONIC GERD characterized by INTESTINAL METAPLASIA WITHIN THE ESOPHAGEAL SQUAMOUS MUCOSA

This is a Pre-Malignant Condition

10% of people with chronic GERD/reflux esophagitis get it –> 0.2-2% of Barrett’s patients get DYSPLASIA –> 10% of these patients develop adenocarcinoma

Question 10

Progression of Barrett’s

Answer 10

REFLUX esophagitis –> Barrett’s –> Barrett’s with low grade dysplasia –> Barrett’s with high grade dysplasia –> Adenocarcinoma

Question 11

Diagnosing Barrett’s

Answer 11

Endoscopic evaluation shows abnormal mucosa ABOVE the Gastro-esophageal junction (intestinal metaplasia of the stomach is NOT indicative)

Histology shows intestinal metaplasia (goblet cells)

Question 12

Gross and Histo of Barrett’s

Answer 12

Gross –> Normally, there is a clear divide between the stomach and esophagus

In Barrett’s, the delineation is LOST, and the esophagus goes from white-pink to DEEP RED in color

Histo –> Transition from SQUAMOUS to COLUMNAR MUCOSA –> many large, vacuolated cells with basal nuclei (GOBLET CELLS with MUCIN)

Question 13

Treating BE

Answer 13

If high grade dysplasia is present (larger, pleomorphic cells) and the patient is young enough (40-50) –> ESOPHAGECTOMY because of the high association with invasive adenocarcinoma

Older patients –> Endoscopic mucosal resection to preserve the muscle layer

Question 14

Most common esophageal neoplasm?

Answer 14

SQUAMOUS CELL CARCINOMAS

But adenocarcinomas are on the rise

Question 15

Squamous Papillomas

Answer 15

Most common BENIGN epithelial tumor of the esophagus

Prevalence = 1%

HIGH ASSOCIATION WITH HPV

Gross – exophytic broad based, elevated polyploid nodule

Histo – EXOPHYTIC type, ENDOPHYTIC type, SPIKE type

All show PAPILLOMATOSIS and KOILOCYTOSIS (active viral infection)

Question 16

Leiomyoma

Answer 16

Most common MESENCHYMAL tumor of the esophagus

8% prevalence

Gross - round tumor with CLEAR boundaries

Histo - SPINDLE cells with eosinophilic cytoplasm and NO nuclear atypia

Question 17

Esophageal ADENOCARCINOMA

Answer 17

Arise after chronic GERD develops into BARRETT’S with high grade dysplasia

Found in WHITES, M > F

Associated with chromosomal abnormalities and the p53 gene

Gross – POLYPLOID, ULCERATED TUMOR at the Gastroesophageal JUNCTION

Histology –> GLANDS, mucinous, Signet Ring Cells, Nests of cells

5 year survival is 80% if stage T1

Drops dramatically if advanced, and that is unfortunately more common

Question 18

Squamous Cell Carcinoma

Answer 18

Can occur in the MIDDLE THIRD of the esophagus (as opposed to just at the GE like adeno)

Begin as in situ lesions termed SQUAMOUS DYSPLASIA

Associated with achalasia (lack of peristalsis in esophagus), chronic esophagitis, strictures, alcohol, tobacco

Blacks 4x more than whites, M > F

Gross - large ulcer in the MIDDLE of the esophagus!

Histo - Differentiated squamous cells; eosinophilic ctyoplasm, great boundaries between cells –> “bridging”

Question 19

Markers for Adeno vs. SCC

Answer 19

Adeno = MUCIN +

SCC = P53+, CK5/6+