Histopathology 10 - Upper GI disease

Question 1

What is the “Z line” in the GI tract?

Answer 1

point at which epithelium transitions squamous → columnar

Question 2

What are the 3 layers of the oesophageal wall?

Answer 2

Mucosa (epithelium → lamina propria → muscularis mucosa)

submucosa

muscularis propria

Question 3

Label the following diagram?

Answer 3

Question 4

What are the three layers of the stomach?

Answer 4

1. gastric mucosa and columnar epithelium
2. non-specialised (antrum) or specialised (body) glands in lamina propria
3. mucalaris mucosae

Question 5

Where are goblet cells usually found and what do goblet cells in the stomach indicate?

Answer 5

Intestine

intestinal metaplasia

Question 6

which part of the somach contains the most specialised glands

Answer 6

body and fundus create acid and enzymes

Question 7

where is H pylori associated gastritis often found?

Answer 7

antrum (and pyloric canal)

Question 8

In a normal duodenum, what is the villous:crypt ratio, what type of cells are found?

Answer 8

2:1

glandular epithelium with goblet cells - intestinal type epithelium

Question 9

What are the histological features of acute oesophagitis?

Answer 9

LOTS of neutrophils (acute inflammation)

Question 10

What is the most common cause of acute oesophagitis?

Answer 10

GORD

Question 11

What are the most common complications to remember of most GI pathologies?

Answer 11

Ulceration
Haemorrhage
Perforation
Stricture

Question 12

Recall the aetiology of Barret’s oesophagus

Answer 12

metaplastic process (squamous → columnar epithelium) in lower oesophagus

AKA columnar-lined oesophagus (CLO)

Question 13

What are the two types of Barret’s oesophagus?

Answer 13

CLO

metaplasia WITHOUT goblet cells

= gastric metaplasia

CLO with IM

metaplasia WITH goblet cells

= intestinal metaplasia (IM) - higher cancer risk

Question 14

What is gastric metaplasia?

Answer 14

Metaplastic change in oesophagus without goblet cells

Question 15

What is gastric intestinal type metaplasia?

Answer 15

Replacement of squamous epithelium with metaplastic columnar epithelium WITH goblet cells present

Question 16

Describe the histological changes seen

Answer 16

1. Normal
2. CLO
3. CLO with IM - contains goblet cells

Question 17

If reflux oesophagitis causes a perforation of the oesophagus, what will be the result?

Answer 17

Mediastinitis

Question 18

What is the most common sequence of pathological progression to cancer in the upper GIT?

Answer 18

Metaplasia –> dysplasia –> Cancer (flat pathway)

1. Metaplasia (reversible)
2. Dysplasia (some cytological/histological features of malignancy, no BM invasion)
3. Adenocarcinoma - abnormal cells invade through BM

(as opp to lower GI - adenoma -> carcinoma pathway polyp)

Question 19

What is the most common type of oesophageal carcinoma in developed coutries?

Answer 19

Adenocarcinoma

Question 20

Where does adenocarcinoma of the oesophagus usually develop?

Answer 20

Lower oesophagus (bottom third)

Question 21

Why is prognosis for oesophageal cancer particularly poor?

Answer 21

Most patients are not suitable for resection surgery

Question 22

Which type of oesophageal cancer is most strongly associated with GORD?

Answer 22

Adenocarcinoma

Question 23

What are some histological features of oesophageal adenocarcinoma?

Answer 23

Glandular epithelium

Mucin

Question 24

What is the most common type of oesophageal cancer in developing coutries?

Answer 24

Squamous cell carcinoma

Question 25

Which type of oesophageal cancer is most associated with smoking and alcohol?

Answer 25

Squamous cell carcinoma

Question 26

Where in the oesophagus does squamous cell carcinoma tend to present?

Answer 26

Mid/lower oesophagus (upper 2/3rds)

Question 27

What are some histological features of squamous cell oesophageal carcinoma?

Answer 27

nvades submucosa Cells form keratin (defining feature) Cells have intercellular bridges

Question 28

What are some causes of oesophageal varices?

Answer 28

Portal HTN Porto-systemic anastomoses Haemorrhoids

Question 29

What are the 3 main causes of acute gastritis?

Answer 29

Aspirin/NSAIDs Alcohol H pylori

Question 30

What are some histological features of acute gastritis?

Answer 30

Neutrophils (acute)

Question 31

What are the 3 major causes of chronic gastritis?

Answer 31

ABC Autoimmune (antiparietal cell Ig, affects body) Bacterial (H pylori, affects antrum) Chemical (NSAIDs, bile reflux, affects antrum) Disease (IBD - Crohn's)

Question 32

What are the histological features of chronic gastritis?

Answer 32

Lymphocytes (chronic) may have co-existent neutrophils due to co-existent acute inflammatory processes

Question 33

Which types of neoplasm is H pylori associated with?

Answer 33

Adenocarcinoma Lymphoma (MALToma) - lymphoid follicles in germinal centres

Question 34

What would stomach biopsy show in H pylori?

Answer 34

lymphoid follicles

Question 35

How do H pylori inject toxin into the mucosa?

Answer 35

cag-A-positive H pylori - needle like appendage that injects toxin into intracellular junctions → bacteria attach more easily

Question 36

Which strain of H pylori is associated with more aggressive chronic gastritis?

Answer 36

cag-A positive

Question 37

Gastric ulcer vs erosion

Answer 37

Erosion = not full thickness (before mucolaris mucosa not past lamina propria) Ulcer = full thickness erosion (past muscularis mucosa all the way to submucosa) Erosion = before muscularis mucosa (not into submucosa)

Question 38

how to differentiate between chronic and acute ulcers?

Answer 38

Fibrosis no fibrosis → ulcer can heal

Question 39

Why might you biopsy a gastric ulcer?

Answer 39

ALL gastric ulcers should be biopsied to exclude malignancy

Question 40

What will be the result of a perforated gastric ulcer?

Answer 40

Peritonitis

Question 41

What is gastric epithelial dysplasia?

Answer 41

Abnormal epithelial pattern of growth

Question 42

What is the key cytological feature of gastric epithelial dysplasia?

Answer 42

High nuclear cytoplasmic ratio Some cytological / histological features of malignancy but no invasion through the basement membrane Cancer = invasion through the BM

Question 43

What is the difference between gastic dysplasia and gastric Ca?

Answer 43

Invasion of basement membrane

Question 44

What type of carcinoma is the most common type of gastric cancer?

Answer 44

Adenocarcinoma

Question 45

Where is gastric cancer most common?

Answer 45

Japan, by far

Question 46

What are the morphological categories of gastric cancer?

Answer 46

Intestinal Diffuse

Question 47

What is the intestinal pattern of gastric adenocarcinoma?

Answer 47

Well-differentiated

Question 48

What is the diffuse pattern of gastric adenocarcinoma?

Answer 48

Signet ring cells Poorly differentiated

Question 49

What is linitis plastica?

Answer 49

No focal lesion in stomach, but whole thing is thickened and static - due to diffuse adenocarcinoma

Question 50

What is a gastrointestinal stromal tumour? (GIST)

Answer 50

Tumour of the interstitial cells of Cajal in the stomach - a SARCOMA

Question 51

What is the cause of gastric MALToma?

Answer 51

Chronic inflammation, usually due to H pylori

Question 52

What are gastric MALTomas composed of?

Answer 52

B cells H. pylori + lymphoma → crypts full of neutrophils → good because if you treat H. pylori, the lymphoma could be reversed

Question 53

What is the first-line treatment of gastric MALToma?

Answer 53

H pylori treatment CAP (clarithromycin, amoxicillin, PPI)

Question 54

Which type of gastrointestinal tract ulcers are always benign?

Answer 54

Duodenal

Question 55

How does H pylori impact the duodenum?

Answer 55

↑ stomach acid production in antrum → spills to dudenum chronic inflammation and gastric metaplasia with helicobacter infection intestinal epithelium will change → like gastric epithelium bc it is well designed to deal with acid

Question 56

What is cryptosporidiosis?

Answer 56

Protozoal GIT infection seen in immunosuppressed patients

Question 57

Where does giardia lamblia infection cause pathology?

Answer 57

Villi of GIT

Question 58

What is the route of transmission of giardia?

Answer 58

Faeco/oral route

Question 59

What is the cause for duodenal H pylori disease?

Answer 59

almost 100% H pylori

Question 60

How are the villi damaged in coeliac disease?

Answer 60

T-cell response to gliadin → damaged villi → crypt hyperplasia attempts to regenerate damaged villi

Question 61

In what condition are increased numbers of intraepithelial lymphocytes in the GIT seen?

Answer 61

Coeliac

Question 62

What are the 3 main histological features of coeliac?

Answer 62

Crypt hyperplasia Villous atrophy Increased numbers of intraepithelial lymphocytes

Question 63

Which two antibodies are required for diagnosis of coeliac disease?

Answer 63

``` Endomysial (anti EMAs) Tissue transglutaminase (anti TTG) ```

Question 64

Where is MALToma associated with coeliac likely to be located?

Answer 64

Duodenum

Question 65

What is the type of MALToma as a result of coeliac disease called?

Answer 65

Enteropathy associated T cell lymphoma T cell lymphoma ( vs lymphomas in stomach due to H. pylori are B cell lymphomas)

Question 66

what is lymphocytic duodenitis?

Answer 66

inflammatory changes without architectural changes many people with this either have Coeliac’s or are going to develop Coeliac’s)

Question 67

what is another cause of malabsorption with similar histology to Coeliac’s?

Answer 67

tropical sprue

Question 68

What would duodenal biopsy show in Coeliac disease?

Answer 68

ON gluten rich diet villous atrophy OFF gluten rich diet normal