Esophagus pathology

Question 1

Review the 4 layers of the esophagus

Answer 1

Question 2

Review normal esophagus layers

Answer 2

Basal cells normally 3 cells thick. More than that suggest injury

Papillae should be half thickness of squamous epithelium; when it extends to surface, that’s a reactive sign of injury

Question 3

Review the epithelium at GEJ

Answer 3

Gastric cardia >> columnar epithelium

Distal esophagus >> squamous epithelium

Question 4

What are the types of tracheoesophageal abnormalities? (3)

Answer 4

Pure Esophageal atresia

Pure tracheoesophageal fistula

Esophageal atresia w/ distal tracheoesophageal fistula

Question 5

The slide below is characteristic of which esophageal dysmotility disorder?

Answer 5

Achalasia

**remember that the lost neurons are inhibitory, that’s why you have hypertrophic nerves/increased LES tone**

Question 6

What is the pathology below?

Answer 6

Candida esophagitis

*endoscopy: fibrinopurulent exudate, whitish-yellow plaques

presents w/ dysphagia, odynophagia

**notice inflammation, and increased papillae thickness**

*usually immunocompromised*

(can also visualize on GMS stain)

Question 7

___ is characterized by sharply punched out ulcers on gross pathology, and neutrophils w/ Cowdry A inclusions, multinucleation, margination and molding

Answer 7

Herpes esophagitis is characterized by sharply punched out ulcers on gross pathology, and neutrophils w/ Cowdry A inclusions, multinucleation, margination and molding

**pts are immunocompromised**

Question 8

What is the pathology below?

Answer 8

Herpes esophagitis

Question 9

What is the pathology below?

Answer 9

Herpes esophagitis

Question 10

You evaluate a pt for esophagitis as the pt presents w/ dysphagia and odonyphagia. You take a biopsy of the pts esophagus and discover ulcers w/ surrounding inflammation, as well as inclusions in the stromal and endothelial cells. There are also owl eye inclusions in the nuclei of the cells.

What is on your differential?

Answer 10

CMV esophagitis

Question 11

What is the pathology below?

Answer 11

CMV esophagitis

**note owl eyes and ulcerations w/ inflammation**

Question 12

A young pt (4 yo) presents w/ dysphagia, feeding intolerance, symptoms of esophageal reflux and has a history of asthma. You do a biopsy for this patient and you find >15/high power field eosinophils clustering near the surface of the squamous epithelium. On endoscopy you also see linear furrows (rings)

What is the diagnosis?

Answer 12

Eosinophilic esophagitis

Question 13

What is the pathology below?

Answer 13

Mild GERD

**notice the increase in purple, i.e. increased basal cell thickness, elongated papilla and diffuse eosinophils**

Question 14

You are evaluating a biopsy for a pt with chronic GERD. Biospy shows goblet cells/columnar epithelium. You also do an endoscopy for the pt, which reveals salmon-colored mucosa.

What is the diagnosis?

Answer 14

Barrett’s esophagus

Question 15

What condition is ass’d w/ the pathology below?

Answer 15

Barret’s esophagus

Question 16

T/F: Low and high grade dysplasia Barret’s esophagus both metastasize

What is the difference between intramucosal carcinoma and invasive adenocarcinoma?

Answer 16

Falsehood. Low and high grade dysplasia in Barret’s does not metastasize

Intramucosal carcinoma is invasion into the lamina propria/muscularis mucosa but has a much lower risk of metastasis; treated w/ mucosal resection

Invasive adenocarcinoma is invasion into submucosa that carries a higher risk of metastasis and may require esophagectomy

Question 17

Where in the esophagus are all these esophageal disorders most likely to occur?

Answer 17

Distal esophagus

Distal esophagus

Distal esophagus

Question 18

What is the pathology below?

Answer 18

Esophageal Adenocarcinoma

Question 19

What is the pathology below?

Answer 19

Adenocarcinoma

Question 20

Where in the esophagus does squamous cell carcinoma and adenocarcinoma occur?

Answer 20

Squamous cell carcinoma occurs in the middle esophagus whereas adenocarcinoma occurs in the distal esophagus

**squamous cell carcinoma arises from squamous epithelium - see slide 46 and 47**

Keratin pearls! Keratin pearls!

Question 21

A 60 year old patient presents with worsening dysphagia. An endoscopy is performed which shows nests of atypical keratinizing squamous epithelium in desmoplastic stroma. Which of the following is true?

A.The patient likely has long standing reflux

B.The lesion arose in the setting of intestinal metaplasia

C.The lesion is present at the gastroesophageal junction

D.The patient likely has a smoking or drinking history.

Answer 21

D. Recall that squamous cell carcinoma is ass’d w/ smoking and alcohol use

Question 22

A patient is biopsied and is diagnosed with intestinal metaplasia with high grade dysplasia. Which of the following is likely true?

A.Her lesion can metastasize.

B.She likely has had long-standing reflux.

C.She is immunosuppressed

D.The lesion is in the mid esophagus.

Answer 22

B. This pt likely has Barret’s esopagus, which is ass’d w/ a history of longstanding GERD