Pathology of the mouth, oesophagus and stomach

Question 1

Oral cancer epidiemiology

Answer 1

1% of all cancers

Question 2

Types of oral cancer

Answer 2

Squamous cell carcinoma 95% Melanoma Adenocarcinoma

Question 3

Risk factors for oral cancer

Answer 3

Alcohol, smoking & chewing tobacco >men rare in younger

Question 4

Examination of the mouth

Answer 4

mouth ulcer that does not heal within 2-3 weeks should be examined by a health care professional

Question 5

Treatment of oral cancer

Answer 5

-build up strength -speech therapy -relearn eating

Question 6

Anatomy of the oesophagus

Answer 6

-muscular tube -25cm -posterior to the trachea Course -laryngopharnx - anterior aspect of the neck - enters mediastinum Two sphincters Upper- skeletal muscle lower –> smooth muscle

Question 7

Histology of the oesophagus

Answer 7

Mucosa (non keratinised squamous epithelium) Lamina propria Skeletal muscle - CILO - upper 1/3 - skeletal -middle 1/3 mixed -lower 1/3 smooth Adventitia

Question 8

Oesophageal infections

Answer 8

Candida oesophagitis Herpes simplex virus

Question 9

Candida oesophagitis

Answer 9

Active chronic inflammation due to candida albicans Many neutrophils esp near the superficial surface of the epithelium Staining using a PAS stain confirms the spores and hyphae Common in immunocompromised

Question 10

Herpes simplex virus

Answer 10

Causes inflammatory exudate with cells (slough) Visible atypical squamous cells (clear cytoplasm) Immunohistochemistry with an antibody can reveal the HSV infection - common in immunocompromised

Question 11

Oesophagus inflammation - chemicals

Answer 11

Peptic oesophagitis/ GORD Causitics - lye (NaOH, causitic soda) Pills sticking e.g iron (can cause ulceration)

Question 12

Eosinophillic oesophagitis

Answer 12

Characterised by - eosinophills infiltrating epithelium - allergic - responsive to steroids - endoscoopic like rings :trachealization LOTS OF EOSINOPHILS - dietary sensitizer, fluticasone

Question 13

Oesophageal cancers: presentation and types

Answer 13

Late presentation (T3 stage) High lethality Dysphagia for solids, then liquids Weight loss Pain and dyspepsia Haematemesis and melaena Two types: - squamous carcinoma - associated with smoking and drinking -adenocarcinoma - obesity and gord

Question 14

OG junction

Answer 14

Squamous collumnar junction Cancer at this junction is increasing: short segment of barrets oesophagus or association with gastric pathology

Question 15

What classification is used to classify gastric, oesophagus and junctional cancers?

Answer 15

Siewarts classification above –> 1 at–> 2 Below –> 3

Question 16

Gastro-oesophageal reflux disease definition

Answer 16

retrograde passage of gastric contents into the oesophagus causing troublesome symptoms (>2 heartburn episodes/wk) and/ or cpmplications

Question 17

Symptoms of GORD

Answer 17

due to reflux being sufficient to impair quality of life:

Oesophageal

• heartburn (burning, retrosternal discomfort after meals, lying, stooping relieved by antacids)
• epigastric pain
• waterbrush (mouth fills up with saliva)
• odynophadia (painful swallowing, eg from oesophagitis or ulceration)

Extra-oesophageal

• non cardiac chest pain
• wheeze- nocturnal asthma
• chronic cough
• laryngitis

Question 18

Pattern of GORD

Answer 18

Oesophagitis: inflammation of squamous epithelium secondary to acid damage can cause strictures to Barrets oesophagus: metaplasia of squamous to collumnar caused by chronic acid damage to adenocarcinma - accumulating cellular genetic changes causing dysplasia and ultimately cancer

Question 19

Causes of GORD

Answer 19

• Lower oesophageal sphincter hypotension
• hiatus hernia
• loss of peristaltic funciton
• abdominal obesity
• gastric acid hypersecretion
• smoking and alcohol
• pregnancy

Question 20

Seattle protocol

Answer 20

estimate dysplasia four biopsies every 2cm

Question 21

Investigations of GORD

Answer 21

• endoscopy if symptoms >4 weeks
  
  • persistent vomitting
  • GI bleeding/ iron deficiency
  • palpable mass
  • age >55
  • dysphagia
  • symptoms despite treatment
• Barium swallow - hiatus hernia
• 24 hr oesophageal pH monitoring + manometry help diagnose GORD when endoscopy is normal

Under the age 45 < symptoms are relatively common and can be treaed empirically. Investigation only if fails to repsond to treatment

Over the age of 45 - reflux can be confirmed by 24h continuous pH monitoring. Peaks of pH change must correspond to symptoms. OGD should be perfomed in all new cases to rule out oesophageal malignancy

Question 22

Treatment of GORD

Answer 22

• Encourgage- raising the bed head + weight loss, smoking cessation, small regular emals
• Avoid- hot drinks, alcohol, citrus fruits, tomatoes, onions, fizzy drinks, drugs affecting LE motility (nitrates, cholinergics, Ca2+ channel blockers - relax the LES) or that damage the mucosa (NSAIDs, bisphosphonates)
• Drugs - antacids e.g magneisum trisilicate (10ml/8h) or Gaviscon advance relieve symptoms), for oesophatitis (PPI - lansoprazole 30mg/24hr)
• Surgery - aims to increase resting lower oesophageal spincter pressure, consider in severe GORD (confirm by PH-monitoring/manometry) if drugs are not working. Atypical symptoms (cough, laryngitis) are less likely to improve with surgery compared to patients with typical symptoms - Nissen fundoplication

Question 23

Recognizing dysplasia

Answer 23

“reactive changes, inflammation” none - indefinte for dysplasia mild to moderate - low grade (nuclei stratified, cells polarise) severe- high grade(polarity lost no prominent nucleloi)

Question 24

Gastritis causes

Answer 24

acute - alcohol, NSAIDs, severe trauma (burns, surgery) Chronic - (ABC) - autoimmune, bacterial, chemical

Question 25

Acute gastritis

Answer 25

Acute inflammation reaction at the superficial mucose, with infiltration of neutrophils Patho: causitive agents inhibit PGs (portect gastric mucosa) - damage ranges from erosions- ulcers

Question 26

Autoimmune atrophic gastritis

Answer 26

autoimmune destruction of parietal cells 1. IF needed to absorb vitamin B12 secreted by parietal cells 2. In terminal ileum Cubulin is the receptor for B12-IF complex 3. Amnionless then mediates endocytosis and B12 absorption In absence developses macrocytic anaemia Caused by malabsoprtion of vitamin b12 anti-parietal cell antibodies in blood Eventual complete loss of parietal cells from gastric mucosa with pseudopyloric and intestinal metaplasia persistent inflammation promotes epithelial dysplasia and cancer

Question 27

Zollinger-Ellison syndrome

Answer 27

Hypersecretion of gastrin by an endocrine tumour in pancreas or DD Leading to increased gastric acid ouptu and florid peptic ulceration

Question 28

Helicobacter Pylori gastritis

Answer 28

Spiral flagellae, gram negatie, microareophillic bacterium Produces urease Diseases associatedL -gastritis -DU -GU -gastric adenocarcinom and gastry lymphoma Methods of detection - rapid urease test at endoscopy -Histology -Culuture (useful for sensitivity to antbiotics -urea breath test -serology Eradicate with triple therapy e.g omeprazole, metrnoidazole and clarithromycin

Question 29

Chemical gastritis

Answer 29

Characteristic morphology -few inflammatory cells -surface congestion oedema, elongation of gastric pits, tortosity, reactive hyperplasia/atypia, ulceration Antrum more than corpus Bile reflux, NSAIDs, ehtanol, oral iorn are typical causes

Question 30

Gastric cancer

Answer 30

historically distal \> proximal strongly associated with chronic gastritis: typically H pylori or autoimmune Background of atrophic mucosa with chronic inflammation, intestinal metaplasia, dysplasia Dysplasia may be flat or adenoma-like Intestinal versus diffuse types Proximal versus distal- distinct epidiemoiology

Question 31

Complications of GORD

Answer 31

* oesophagitis, ulcers, benign stricture, IDA * Gord may induce barrats oesophagus * 0.6-1.6%/yr of those with low grade - progress to cancer * aspiration pneumonia * upper GI bleeding

Question 32

Hiatus hernia definition

Answer 32

The presence of part or all of the stomach within the thoracic cavity, usually by protrusion through the oesophageal hiatus in the diaphragm

Question 33

Clinical features

Answer 33

* common: 30% of patietns \>50y, especially obese women * 50% have GORD

Question 34

Types of Hiatus hernia

Answer 34

* **Sliding hiatus hernia** 80%- is where the GOJ slides up into the vhest- acid reflux often happens as the LES become less competent * **Rolling hiatus hernia** 20% - is where the GOJ remain in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus.. As GOJ remains intact, gross acid reflux is uncommon

Question 35

Diagnosis of hiatus hernia

Answer 35

* Upper Gi endoscopy - to exclude oeosphageal mucosal pathology * **Video barum swallow** - extent and type - **best choice** * CT scanning of the thorac- investigation of choice in acute presentations

Question 36

Treatment of hiatus hernia

Answer 36

* **Medical** * ​reduce acid consumption- stop smoking, lose weight, reduce alcohol consumption * counteract acid secretion- PPIs, symptomatic relief with antacids * promote oeosphageal and gastric emptying - promotilants e.g metoclopramide * **Surgical** * **​**rare * indicated for - persistant symptoms despite max med therapy, established complications of rolling hernia such as volvulus or obstruction