Gastrointestinal tract

Pathology
 Diseases of the Esophagus
• Tracheoesophageal fistula
• Hiatal hernia
• Esophageal diverticula
• Achalasia
• Esophageal varices
• Inflammatory and related disorders of the esophagus
• Esophagus tumors
 Symptoms of esophageal disorders
• Dysphagia (difficulty in swallowing)
▪ which is attributed either to deranged esophageal motor function or to
narrowing or obstruction of the lumen.
• Heartburn (retrosternal burning pain)
▪ usually reflects regurgitation of gastric contents into the lower
esophagus.
• Less commonly, Hematemesis (vomiting of blood) and melena(blood in
stool) are evidence of severe inflammation, ulceration, or laceration of
the esophageal mucosa.
 Normal anatomy
• Extends from C6 to T11 or T12
• Length 25 cm in adult (on average)
• Three points of luminal narrowing:
1.Cricoid cartilage
2.Where left mainstem bronchus crosses anterior to the esophagus
3.Diaphragm
• Upper and lower sphincters defined manometrically, no morphologic
landmarks
• No serosa- Lesions can easily spread into mediastinum
Histology
 Congenital anomalies
Tracheoesophageal fistula
• Esophagus segment is a thin, non canalized cord with a proximal
blind pouch connected to pharynx and distal pouch leading to
stomach
• Esophageal agenesis usually near tracheal bifurcation;
• usually associated with fistula connecting the upper or lower
pouch with the trachea or a bronchus
• Discovered after birth due to immediate regurgitation after feeding
• Must surgically correct early since incompatible with life;
 Hiatal Hernia
an abnormal protrusion of the stomach into the thoracic cavity through a lax diaphramatic hiatus.

• Sliding hernia(95%) - GEJ and the gastric cardia • Para-esophageal (rolling) hernia- part of the
slide up into the posterior mediastinum (houreglass gastric fundus herniates into thorax.GEJ stay in its
stomach) anatomic location
• Associated with GERD and ulcerations. • Present with early satiety and pain
• vulnerable to strangulation and infarction
Diverticula
 Esophageal diverticula
• An outpouching of the alimentary tract that contains all visceral layers
• False diverticulum is an outpouching of mucosa and submucosa only
• Zenker diverticulum – immediately above the upper esophageal
sphincter
• Traction diverticulum – near the midpoint of esophagus
• Epiphrenic diverticulum – immediately above LES
• Typical symptoms are dysphagia, regurgitation, halitosis, retrosternal
pain and aspiration with resultant pneumonia is a significant risk
 Achalasia
• Characterized by
– Aperistalsis
– Partial or incomplete relaxation of LES
– Increased resting tone of LES
• Etiology - damage to the inhibitory ganglion cells of esophageal
myenteric plexus.
– Primary(idiopathic)
– Secondary - chagas disease (Trypanosoma cruzi )
• There will be progressive dilation of esophagus above the level of LES
• Present with progressive dysphagia to both solid and liquid,
regurgitation, retrosternal pain and halitosis.
• Complications of achalasia
– In about 5%, possibility of developing SCC
– Others
• candidal esophagitis,
• diverticula
• aspiration with pneumonia
 Lacerations (Mallory-Weiss syndrome)
• Longitudinal tears at GE junction or in proximal gastric
mucosa
• Usually due to severe retching and associated with
alcoholism (vomiting and reflux with alcoholic stupor)
• Tears may be mucosal or full-thickness
• can lead to a painful acute upper GI bleeding and in
extreme cases to Boerhaave syndrome (spontaneous rupture
of esophagus resulting in mediastinitis and subcutaneous
emphysema).
• Cause 5-10% of upper GI bleeds, usually limited
 Esophageal Varices
• Dilated tortuous vessels, usually submucosal, that develop due
to portal hypertension (prolonged or severe).
• Present in 90% of cirrhotic patients
• May rupture and cause massive hemorrhage, which could be
fatal.
• Associated with alcoholism, hepatic schistosomiasis etc.
A. angiogram demonstrates several tortuous esophageal varices. (B)
Collapsed varices are present in this postmortem specimen
corresponding to the angiogram.
Dilated varices beneath intact squamous mucosa
 Esophagitis
• Defined as epithelial damage and inflammation
• Most common cause is gastroesophageal reflux (reflux of
gastric contents into lower esophagus);
• Infectious causes are much less common
• Histologic changes may be severe (erosion, ulceration,
exudative) or subtle
 GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Backflow of gastric acid due to inappropriate relaxation of the LES
Irritation of the mucosa causes “reflux esophagitis”
• RF: obesity, stress, smocking, alcohol, caffeine, hiatal hernia,
pregnancy etc.
• Presents with heartburn, dysphagia and regurgitation (exaggerated
nocturnally or on laying down)
• Other symptoms :aspiration of gastric content, hoarseness, erosion of
tooth enamel
• Complication - Barrett's esophagus, iron deficiency anemia (chronic
bleeding), stricture.
• Usually diagnosed with upper GI endoscopy, PH monitoring
Morphologic changes in reflux esophagitis include
-simple hyperemia
-inflammatory infiltrate in the squamous epithelium
-basal zone hyperplasia >20%
-elongation of lamina propria papillae occur
 Barrett Esophagus
• a complication of long standing gastro-esophageal reflux
• Characterized by replacement of the distal esophageal
mucosa by metaplastic columnar epithelium as a response to
prolonged injury
• Grossly or endoscopically appear as a red velvety/smooth, and
soft/ mucosa
A) Normal gastroesophageal junction. (B) Barrett esophagus. Note the small
islands of residual pale squamous mucosa within the Barrett mucosa
 Histologic appearance of the gastroesophageal junction in Barrett esophagus. Note the transition
between esophageal squamous mucosa (left) and Barrett metaplasia, with abundant metaplastic goblet
cells (right)
 Barrett Esophagus
• Dysplasia may be present
• Is associated with 30-40 fold increased risk of developing
adenocarcinoma than general population.
Infectious and chemical esophagitis
Can occur due to
• Ingestion of mucosal irritants such as alcohol, corrosive , acids
or alkali
• Cytotoxic anticancer therapy
• Infection after bacteremia or viremia , HSV and CMV in
immunocompromised
• Fungal infections in immunocompromised – candida
• Uremia
 Tumors of the esophagus
Benign tumors
• Mostly mesenchymal in origin
• include leiomyomas , fibromas , lipomas hemangioma . . . .
• Epithelial – squamous papilloma
• Fibrovascular polyps
• Inflammatory polyp
 Tumors of the esophagus

Malignant Tumors
Squamous cell carcinoma
• represent the largest majority
• recently its incidence is declining and adenocarcinomas are
increasing
• Occur in adults over 50
• Has male preponderance(predominance, prevalence)
 Risk Factors for SCC of the Esophagus
Esophageal Disorders
⮚ Long-standing esophagitis
⮚ Achalasia
⮚ Plummer-Vinson syndrome (esophageal webs, microcytic hypochromic anemia,
atrophic glossitis)
Life-style
⮚ Alcohol consumption
⮚ Tobacco abuse
Dietary
⮚ Deficiency of vitamins (A, C, riboflavin, thiamine, pyridoxine)
⮚ Deficiency of trace metals (zinc, molybdenum)
⮚ Fungal contamination of foodstuffs
⮚ High content of nitrites/nitrosamines
Genetic Predisposition
⮚ Racial predisposition
⮚ Tylosis (hyperkeratosis of palms and soles)
Squamous cell carcinoma of the esophagus
• About 20% are located in the upper third,
50% in the middle third, and 30% in the lower.
Three morphologic patterns:
1. Protruded (60%) – polypoid exophytic
lesion
2. Flat (15%)- a diffuse infiltrative form that
spreads within the wall of the esophagus
causing thickening, rigidity and narrowing
3. Excavated (25%) – a necrotic cancerous
ulceration that excavates deeply into
surrounding structures
• Most are moderately to well differentiated
• Local extension into adjacent mediastinal
structures occur early
– Tumors in the upper third
• to cervical lymph nodes
– Those in the middle
• to mediastinal, paratracheal and
tracheobronchial
– Those in the lower third
• to gastric and celiac groups of nodes
Clinical presentation includes
–Slow onset
–Dysphagia and later obstruction
–Weight loss
–Hemorrhage
• Esophageal Adenocarcinoma
– Incidence on the rise recently
– Better recognition
– Association with Barrett esophagus
Transition from Barrett esophagus to
adenocarcinoma
• Rx and Px
– Surgery is the first line of treatment
– Five year survival is less than 20%
– Outcome is influenced by
⮚ stage at diagnosis,
⮚ margin involvement and
⮚ vascular invasion
 Review Questions
1. A 23-year-old primigravida gives birth at term to a boy infant.
Ultrasound examination before delivery showed polyhydramnios. A
single umbilical artery is seen at the time of birth. The infant vomits
all feedings, and then develops a fever and difficulty with
respirations within 2 days. A radiograph shows both lungs and the
heart are of normal size, but there are pulmonary infiltrates and no
stomach bubble. What is the most likely diagnosis?
A Achalasia
B Diaphragmatic hernia
C Esophageal atresia
D Hiatal hernia
E Pyloric stenosis
F Zenker diverticulum
 Review Questions
2.A 22-year-old woman has had multiple episodes of aspiration of
food associated with difficulty swallowing during the past year. On
auscultation of her chest, crackles are heard at the base of the right
lung. A barium swallow shows marked esophageal dilation above
the level of the lower esophageal sphincter. A biopsy specimen from
the lower esophagus shows an absence of the myenteric ganglia.
What is the most likely diagnosis?
A Achalasia
B Barrett esophagus
C Plummer-Vinson syndrome
D Sliding hiatal hernia
E Systemic sclerosis
 Review Questions
3.A 30-year-old man has sudden onset of hematemesis after a
weekend in which he consumed large amounts of alcohol. The
bleeding stops, but he has another episode under similar
circumstances 1 month later. Upper gastroesophageal endoscopy
shows longitudinal tears at the gastroesophageal junction. What is
the most likely mechanism to cause his hematemesis?
A Absent myenteric ganglia
B Autoimmune inflammation
C Herpes simplex virus infection
D Portal hypertension
E Vomiting
F Widened diaphragmatic crura
 Review Questions
4.A 57-year-old woman has had burning epigastric pain after meals
for more than 1 year. Physical examination shows no abnormal
findings. Upper gastrointestinal endoscopy shows an erythematous
patch in the lower esophageal mucosa. A biopsy specimen shows
basal zone squamous epithelial hyperplasia, elongation of lamina
propria papillae, and scattered intraepithelial neutrophils with some
eosinophils. Which of the following is the most likely diagnosis?
A Barrett esophagus
B Esophageal varices
C Iron deficiency
D Reflux esophagitis
E Systemic sclerosis
 Review Questions
5. A 55-year-old man has had increasing difficulty swallowing during
the past 6 months. There are no significant findings on physical
examination. Upper gastrointestinal endoscopy shows areas of
erythematous mucosa 3 cm above the Z-line. A biopsy specimen
from the lower esophagus has changes in the mucosal epithelium
illustrated in the figure. Which of the following complications is most
likely to occur as a consequence of this patient’s condition?
A Achalasia
B Adenocarcinoma
C Diverticular formation
D Lacerations (Mallory-Weiss syndrome)
E Squamous cell carcinoma
 Review Questions
1. A 23-year-old primigravida gives birth at term to a boy infant.
Ultrasound examination before delivery showed polyhydramnios. A
single umbilical artery is seen at the time of birth. The infant vomits
all feedings, and then develops a fever and difficulty with
respirations within 2 days. A radiograph shows both lungs and the
heart are of normal size, but there are pulmonary infiltrates and no
stomach bubble. What is the most likely diagnosis?
A Achalasia
B Diaphragmatic hernia
C Esophageal atresia
D Hiatal hernia
E Pyloric stenosis
F Zenker diverticulum
 Review Questions
2.A 22-year-old woman has had multiple episodes of aspiration of
food associated with difficulty swallowing during the past year. On
auscultation of her chest, crackles are heard at the base of the right
lung. A barium swallow shows marked esophageal dilation above
the level of the lower esophageal sphincter. A biopsy specimen from
the lower esophagus shows an absence of the myenteric ganglia.
What is the most likely diagnosis?
A Achalasia
B Barrett esophagus
C Plummer-Vinson syndrome
D Sliding hiatal hernia
E Systemic sclerosis
 Review Questions
3.A 30-year-old man has sudden onset of hematemesis after a
weekend in which he consumed large amounts of alcohol. The
bleeding stops, but he has another episode under similar
circumstances 1 month later. Upper gastroesophageal endoscopy
shows longitudinal tears at the gastroesophageal junction. What is
the most likely mechanism to cause his hematemesis?
A Absent myenteric ganglia
B Autoimmune inflammation
C Herpes simplex virus infection
D Portal hypertension
E Vomiting
F Widened diaphragmatic crura
 Review Questions
4.A 57-year-old woman has had burning epigastric pain after meals
for more than 1 year. Physical examination shows no abnormal
findings. Upper gastrointestinal endoscopy shows an erythematous
patch in the lower esophageal mucosa. A biopsy specimen shows
basal zone squamous epithelial hyperplasia, elongation of lamina
propria papillae, and scattered intraepithelial neutrophils with some
eosinophils. Which of the following is the most likely diagnosis?
A Barrett esophagus
B Esophageal varices
C Iron deficiency
D Reflux esophagitis
E Systemic sclerosis
 Review Questions
5. A 55-year-old man has had increasing difficulty swallowing during
the past 6 months. There are no significant findings on physical
examination. Upper gastrointestinal endoscopy shows areas of
erythematous mucosa 3 cm above the Z-line. A biopsy specimen
from the lower esophagus has changes in the mucosal epithelium
illustrated in the figure. Which of the following complications is most
likely to occur as a consequence of this patient’s condition?
A Achalasia
B Adenocarcinoma
C Diverticular formation
D Lacerations (Mallory-Weiss syndrome)
E Squamous cell carcinoma
Thank you