Pathology of the Oesophagus and Stomach

Question 1

What are oesophageal webs?

Answer 1

Mucosal and sub-mucosal webs protruding into lumen

Question 2

What is achalasia?

Answer 2

Oesophageal sphincter doesn’t open > oesophagus dilates

Question 3

What is a hiatus hernia?

Answer 3

Part of stomach enters thoracic cavity via oesophageal hiatus in diaphragm

Question 4

What can cause infective oesophagitis?

Answer 4

Candida
Viral
- CMV
- HSV

Question 5

In what general types of conditions are numerous eosinophils seen?

Answer 5

Allergic conditions
Parasitic conditions
GORD
Eosinophilic oesophagitis

Question 6

What is the microscopic appearance of eosinophilic oesophagitis?

Answer 6

Squamous mucosa without any glandular mucosa
Acanthotic
Moderate basal cell hyperplasia
Many areas of oedema
Eosinophils

Question 7

What conditions would be considered if granulomas were present in the oesophagus?

Answer 7

TB
Sarcoidosis
Crohn’s disease

Question 8

What is the typical age of patients with eosinophilic oesophagitis?

Answer 8

Young - 20s

Question 9

What is the likely underlying cause of eosinophilic oesophagitis?

Answer 9

Food allergy

Question 10

How may the patient present clinically with eosinophilic oesophagitis?

Answer 10

Dysphagia

Some may have burning in chest

Question 11

What is the treatment for eosinophilic oesophagitis?

Answer 11

Avoid triggering food allergens

Immunosuppression with oral steroids if not settling

Question 12

What part of the oesophagus is best to biopsy in the setting of GORD?

Answer 12

Distal

Question 13

Compare the severity of GORD and eosinophilic oesophagitis if the middle and upper oesophagus are abnormal, too

Answer 13

GORD ascending disease - if middle and upper oesophagus affected > very severe disease
Eosinophilic oesophagitis affects whole oesophagus

Question 14

What is the microscopic appearance of GORD?

Answer 14

Elongated stromal papillae
Mild basal cell hyperplasia
Scattered mixed inflammatory infiltrate

Question 15

What condition can it be difficult to distinguish GORD from on pathology alone?

Answer 15

Eosinophilic oesophagitis, especially if many eosinophils present

Question 16

What is the pathogenesis of GORD?

Answer 16

Gastric contents get into oesophagus due to relaxed sphincter

Question 17

What are the risk factors for GORD?

Answer 17

Smoking
Alcohol
Increased abdominal pressure
- Pregnancy
- Obesity

Question 18

How can patients present clinically with GORD?

Answer 18

Central chest pain

Sore throat, sometimes

Question 19

What is the treatment for GORD?

Answer 19

Antacids

PPIs

Question 20

What are the potential complications of GORD?

Answer 20

Glandular metaplasia - adaptive response to resist acidic contents of stomach

Question 21

What does indefinite for dysplasia mean?

Answer 21

In some conditions, especially if inflammation present, unsure if dysplasia/reactive change to inflammation

Question 22

In which epithelium of the gastrointestinal tract are goblet cells usually present?

Answer 22

Intestinal

Question 23

What features need to be present for the diagnosis of Barretts’ oesophagus?

Answer 23

Intestinal mucosa - has goblet cells

Question 24

What is the microscopic appearance of adenocarcinoma in the oesophagus?

Answer 24

Glands with columnar epithelium

Irregular invasive glands lined by cells with large, hyperchromatic nuclei with some loss of polarity and mitoses

Question 25

What features present in an oesophageal biopsy indicate intestinal metaplasia?

Answer 25

Goblet cells

Question 26

What features distinguish severe dysplasia from invasive adenocarcinoma?

Answer 26

If limited to crypts = dysplasia | If outside crypts = invasive carcinoma

Question 27

What is the management of metaplasia, with no dysplasia in an oesophageal biopsy?

Answer 27

Endoscopic surveillance

Question 28

What is the management of low grade dysplasia in an oesophageal biopsy?

Answer 28

Intensified surveillance | ?Mucosal ablation

Question 29

What is the management of high grade dysplasia in an oesophageal biopsy?

Answer 29

Endoscopic mucosal resection | Prophylactic mucosal ablation

Question 30

What is the management of intramucosal carcinoma?

Answer 30

Curative treatment | ?Endoscopic mucosal resection

Question 31

What is the management of carcinoma in the submucosa and beyond?

Answer 31

Curative treatment

Question 32

What are the main types of carcinoma of the oesophagus?

Answer 32

Adenocarcinoma | Squamous cell carcinoma

Question 33

What are the risk factors for developing adenocarcinoma of the oesophagus?

Answer 33

Barretts' oesophagus

Question 34

What are the risk factors for developing squamous cell carcinoma of the oesophagus?

Answer 34

Alcohol Smoking Achalasia

Question 35

What is the macroscopic appearance of candidiasis of the oesophagus?

Answer 35

Whitish plaques

Question 36

How can the different regions of the stomach be distinguished histologically?

Answer 36

Fundus and body have parietal and chief cells | Antrum has mucus secreting cells

Question 37

Does the lamina propria of the stomach normally contain many mononuclear inflammatory cells?

Answer 37

No, only a few

Question 38

What features indicate that the gastric mucosa is specialised?

Answer 38

Presence of parietal and chief cells

Question 39

Intestinal metaplasia is indicated by the presence of what main feature in the stomach?

Answer 39

Goblet cells

Question 40

What does active chronic H pylori gastritis look like microscopically?

Answer 40

Inflammatory infiltrate Occasional lymphoid aggregates in lamina propria Numerous neutrophils Occasional H pylori

Question 41

What if a biopsy report is out of keeping with the clinical impression?

Answer 41

Where is the mistake?

Question 42

What are the potential complications of H pylori?

Answer 42

Chronic gastritis Dysphagia Gastric carcinoma Gastric lymphoma

Question 43

Where in the intestine is iron absorbed?

Answer 43

Duodenum

Question 44

What is melanosis coli?

Answer 44

Discolouration of mucosa Common in people who take a lot of laxatives Due to macrophages in lamina propria containing lipofuscin

Question 45

What are the two main histopathological types of gastric adenocarcinoma?

Answer 45

Intestinal - papillar/tubular architecture Diffuse - scattered cells - Signet cells - Mucinous type

Question 46

What are the risk factors of gastric adenocarcinoma of the intestinal type?

Answer 46

H pylori gastritis Consumption of smoked foods Smoking Alcohol

Question 47

What is the first step in management of gastric adenocarcinoma?

Answer 47

Partial/total gastrectomy

Question 48

What is the significance of perineural invasion of gastric adenocarcinoma?

Answer 48

Malignant cells can hide along nerves > can spread elsewhere in stomach

Question 49

What is the significance of lymphovascular invasion of gastric adenocarcinoma?

Answer 49

Cancer can spread elsewhere

Question 50

What are centrocyte and centroblast-like cells?

Answer 50

Major malignant cells in follicular lymphoma

Question 51

What technique is used to determine if the cells are CD20, CD3, CD5, etc positive?

Answer 51

Immunohistochemistry | Flow cytometry

Question 52

What types of lymphoma can occur in the gastrointestinal tract?

Answer 52

MALT - most common Follicular DBCL

Question 53

What are two major contributors of prognosis in gastrointestinal stromal tumours (GIST)?

Answer 53

Mitotic rate | Size of tumour

Question 54

What is CD117?

Answer 54

Growth factor receptor

Question 55

What is the relevance to the management of GIST if it is CD117 positive?

Answer 55

Can be blocked by tyrosine kinase inhibitors; eg: Glivec

Question 56

What is the proposed cell of origin of GIST, and what is its function?

Answer 56

Intestinal cells of Cajal Intermediate between neural and muscle cells Responsible for peristalsis