Upper Gi pathology

Question 1

Where is the most common spread of head and neck cancers?

Answer 1

Lymph nodes in the neck, usually on the same side

Question 2

What is a classical presentation of mouth cancer?

Answer 2

An ulcer which persists without a definite, identifiable cause (should heal within 2-3 weeks)

Question 3

What are the main risk factors of oral cancer?

Answer 3

• Smoking
• Alcohol
• HPV can be a factor in some cases (mainly tonsil, oropharynx)

Question 4

What are the histological layers of the oesophagus?

Answer 4

• Mucosa
• Muscularis mucosae
• Submucosa
• Muscularis propria
• Adventitia

Question 5

What is the mucosa in the oesophagus lined by?

Answer 5

Non-keratinising stratified squamous epithelium

Question 6

What is the pathogenesis of reflux oesophagitis?

Answer 6

• Acid, bile and digestive enzymes injure the squamous epithelium lining of the oesophagus
• Increased numbers of inflammatory cells and basal hyperplasia
• Reflux of gastroduodenal secretions

Question 7

Name a fungal infection of the oesophagus

Answer 7

Candida albicans

Question 8

What infection of the oesophagus can occur in immunocompromised patients?

Answer 8

Herpes simplex virus

Question 9

What conditions result in inflammation of the oesophagus?

Answer 9

• Peptic oesophagitis/GERD: reflux of acid/bile
• Caustics: NaOH, caustic soda
• Pills: iron, bisphosphonates, tetracyclines

Question 10

What is the appearance of candida oesophagitis?

Answer 10

White spots

Question 11

What confirms a candida albicans infection of the oesophagus?

Answer 11

• PAS stain

* Spores and hyphae seen

Question 12

What are the symptoms of eosinophilic oesophagitis?

Answer 12

Dysphagia/food sticking

Question 13

What is eosinophilic oesophagitis?

Answer 13

Eosinophils infiltrate the epithelium, it has an allergic aetiology

Question 14

What is eosinophilic oesophagitis responsive to?

Answer 14

Steroids (fluticasone)

Question 15

What is the endoscopic appearance of eosinophilic oesophagitis?

Answer 15

Ring like trachealization

Question 16

What is the histological appearance of eosinophilic oesophagitis?

Answer 16

Large numbers of brightly staining eosinophils infiltrating the oesophageal squamous epithelium

Question 17

Name two oesophageal cancers

Answer 17

• Squamous carcinoma

* Adenocarcinoma

Question 18

What is squamous carcinoma of the oesophagus associated with?

Answer 18

Smoking and drinking

Question 19

What is adenocarcinoma of the oesophagus associated with?

Answer 19

GERD (gastro-oesophageal reflux) and obesity

Question 20

What is Barrett’s oesophagus?

Answer 20

• Metaplastic response to mucosal injury
• Squamous cells become glandular (usually intestinal with goblet cells)
• Associated with benign strictures but also with adenocarcinoma

Question 21

Describe the risk of progression to cancer of Barrett’s oesophagus

Answer 21

• If no dysplasia or aneuploidy the risk is low

* Definite low or high grade dysplasia have a higher risk but the progression to cancer is still low

Question 22

What is the Seattle biopsy protocol?

Answer 22

• Four biopsies every 2cm every 2 years

* Checking for progression to cancer in patients with Barretts oesophagus

Question 23

Describe the spectrum of dysplasia

Answer 23

• Inflammation, reactive changes
• Indefinite for dysplasia - when you cannot be certain
• Mild, moderate (low grade) dysplasia
• Severe (high grade) dysplasia
• Invasive adenocarcinoma

Question 24

Describe low grade dysplasia

Answer 24

• Cells polarised

* nuclei stratified

Question 25

Describe high grade dysplasia

Answer 25

*  Polarity lost *  Nuclei rounder *  Vesicular *  Prominent nuclei *  Abnormal mitoses *  Necrosis

Question 26

What are the causes of acute gastritis in the stomach?

Answer 26

*  Alcohol *  NSAIDs *  Severe trauma (burns, surgery)

Question 27

What are the causes of chronic gastritis?

Answer 27

*  Autoimmune *  Bacterial (H pylori) *  Chemical

Question 28

Explain how autoimmune atrophic gastritis causes anaemia

Answer 28

*  Parietal cells that release intrinsic factor are targeted by anti-parietal cell antibodies in the blood *  Intrinsic factor binds to vitamin B12 in the duodenum once hepatocorrin has been digested *  B12 is needed for haumatopoeisis, lack of B12 results in pernicious anaemia *  Eventual complete loss of parietal cells, pyloric and intestinal metaplasia

Question 29

What are the complications of autoimmune gastritis?

Answer 29

*  Achlorhydria results in bacterial overgrowth *  Hypergastrinaemia (more gastrin) leads to endocrine cell hyperplasia/carcinoids *  Persistent inflammation may lead to epithelial dysplasia and eventually cancer

Question 30

What is Zollinger-Ellison syndrome?

Answer 30

Hypersecretion of gastrin by an endocrine tumour in the pancreas or the duodenum resulting in increased gastric acid output and severe peptic ulceration

Question 31

Discuss helicobacter pylori gastritis

Answer 31

*  Potentially lifelong *  H. pylori colonies the gastric mucosa leading to active chronic inflammation *  IL- 8 from epithelial cells attracts neutrophils *  There are two patterns

Question 32

What are the two patterns of helicobacter pylori gastritis?

Answer 32

*  Antral-predominant gastritis - hypergastrinaemia and duodenal ulceration *  Pan-gastritis- hypochlorhydria, multifocal atrophic gastritis, cancer, intestinal metaplasia

Question 33

What are the causes of a chemical gastritis?

Answer 33

*  Bile reflux *  NSAIDs *  Ethanol *  Oral iron

Question 34

What is the characteristic morphology of chemical gastritis?

Answer 34

*  Few inflammatory cells *  Surface congestion oedema *  Elongation of gastric pits *  Tortuosity *  Reactive hyperplasia/atypia *  Ulceration

Question 35

What is gastric cancer associated with?

Answer 35

*  Helicobacter pylori | *  Autoimmune

Question 36

What are the features of gastric cancer?

Answer 36

*  Background atrophic mucosa *  Chronic inflammation *  Intestinal metaplasia *  Dysplasia

Question 37

What is the Lauren classification of gastric cancer?

Answer 37

*  Intestinal | *  Diffuse

Question 38

What is the most common cause of proximal gastric cancer?

Answer 38

Acid reflux at the OG junction

Question 39

What is the most common cause of distal gastric cancer

Answer 39

Mainly helicobacter pylori infection or autoimmune

Question 40

Describe the histology of diffuse gastric cancer

Answer 40

*  Signet ring cells: individual malignant cells with mucin vacuoles *  Linitis plastica (adenocarcinoma of the stomach): may invade extensively i.e. to muscles without being endoscopically obvious *  weaker link with gastritis

Question 41

Where are the most likely points of metastasis from gastric cancer?

Answer 41

*  Ovaries - krukenberg tumour *  Supraclavicular lymph node (Virchow's) *  Sister Joseph's nodule (umbilical metastasis)

Question 42

What is the associated mutation in familial gastric cancer?

Answer 42

CDH1 - E-cadherin

Question 43

Describe the risk of familial gastric cancer

Answer 43

*  Penetrance is 70-80% (lifelong) *  Small intramucosal foci or diffuse gastric cancer may be numerous *  Prophylactic gastrectomy *  Increased risk of lobular carcinoma of the breast