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Case 8: Anatomical Pathology of Oesophagus and the Stomach 1, image, image…
Case 8: Anatomical Pathology of Oesophagus and the Stomach 1
Congenital Abnormalities of the Oesophagus
Outline the Congenital Abnormalities of the Oesophagus
The Congenital abnormalities which can occur during embryological development of the Oesophagus and the Trachea which both arise from the foregut
The following congenital abnormalities can occur in the Oesophagus and the Trachea:
Oesophageal atresia
Oesophageal atresia is when the upper oesophagus ends in a blind pouch
Tracheoesophageal fistula
Tracheoesophageal fistula is when the lower end of the oesophagus communicates with the trachea
Tracheoesophageal fistula is the most common congenital abnormality involving the oesophagus and trachea
Hiatus Hernia
Outline the types of Hiatus Hernia
There are two types of Hiatus Hernia, depending on exactly which part of the proximal stomach herniates up into the Thorax through the diaphragm
Sliding Hernia
Sliding hernia where the Distal Oesophagus and Proximal Stomach slide upwards
Rolling Hernia
Rolling Hernia is when the loop of the stomach rolls up through the diaphragm along side the oesophagogastric junction
List the causes and complication of Hiatus hernia
Hiatus Hernia can be caused by:
Aging
Increased intra-abdominal pressure
Complications of Hiatus Hernias are as follows:
Reflux oesophagitis
Ulceration
Oesophagitis
List the three main causes of Oesophagitis
Oesophagitis is the inflammation of the oesophagus
The three main causes of Oesophagitis:
Infective
Reflux Oesophagitis
Corrosive injury
Outline the common Infective causes of Oesophagitis
Candida
Herpes simplex virus
Cytomegalovirus
Tuberculosis
Oesophageal Candida
Outline the Macroscopic and Microscopic features of Oesophageal Candida
Macroscopic features of oesophageal candida:
White plaque in the oesophagus
Microscopic features of oesophageal candida:
Fungal spores and hyphae on PAS Stain
Reflux Oesophagitis
Outline Reflux Oesophagitis
Reflux Oesophagitis is the reflux of the stomach contents through the lower Oesophagus Sphincter
This results in the acid or pepsin digesting the oesophageal mucosa
Individuals with Reflux Oesophagitis will present central chests pain
The symptoms of Reflux Oesophagitis are commonly referred to as "Heart burn"
List the Risk Factors and Complications of Reflux Oesophagitis
Risk factors of Reflux Oesophagitis:
Abnormal peristalsis
Increased intra-abdominal pressure
Incompetent lower oesophageal sphincter
Hiatus Hernia
Complication of Reflux Oesophagitis:
Peptic Ulceration
Chronic Haemorrhages which may lead to iron deficiency anaemia
Fibrous stricture
Intestinal metaplasia (Barret Oesophagus)
Barret Oesophagus
Outline Barret Oesophagus
Barret oesophagus is a complication of Reflux Oesophagitis
Barret oesophagus is when the acid reflux causes Intestinal Metaplasia in the Lower Oesophagus
Which is usually line by a Stratified Squamous epithelium
Features of Barret Oesophagus
List the Macroscopic and Microscopic Features of Barret oesophagus
Macroscopic features of Barret oesophagus:
Tongues of red metaplastic mucosa extending up into the normally pale oesophagus
Microscopic Features of Barret oesophagus:
Intestinal type of columnar mucosa with goblet cells replacing adjacent Stratified Squamous Mucosa
Corrosive Injury
Outline the causes of Corrosive Injury
Corrosive injury follows after an ingestion of a strong acid or alkali
Corrosive injury occurs after an attempted suicide or accidental ingestion of harmful substances
Outline the phases of Corrosive Injury
Corrosive injury has the following phases:
Acute Phase
Acute phase of Corrosive Injury is characterised by:
Mucosal Sloughing
Bacterial Infection
Chronic Phase
Chronic phase of Corrosive Injury is characterized by:
Fibrous strictures
Motility disturbance
Oesophageal Varices
Outline the development of Oesophageal Varices
Cirrhosis may lead to Portal Hypertension
As a result of increased pressure, blood bypasses the portal veins.
With shunting of blood through the systemic collaterals and subsequent dilatation of Oesophageal submucosal venous plexus
Bleeding of oesophageal varices can be a cause of death in patients with Liver Cirrhosis
Describe the macroscopic features of Oesophageal Varices
In Oesophageal Varices, there are markedly dilated veins at the Gastroesophageal junction
Oesophageal Carcinoma
List the types of Oesophageal Carcinoma
The two main histological types of Oesophageal Carcinoma have different presentations
They are:
Squamous Cells Carcinoma
Adenocarcinoma
Squamous Cell Carcinoma
Outline the Epidemiology of Squamous Cell Carcinoma
These are the factors which place people most at risk:
Middle-aged males have a greater predisposition
There is a higher incidence of Squamous Cell Carcinoma in the Transkei
Risk factors of Squamous Cell Carcinoma include:
Smoking
Alcohol
Nitrosamines
Fungal contamination of maize
HPV 16 and HPV 18
Morphology of Oesophageal Squamous Cell Carcinoma
Describe the Morphology of Oesophageal Squamous Cell Carcinoma
The morphology of the Oesophageal Squamous Cell Carcinoma typically involves the middle third of the oesophagus
Macroscopic features are similar to other malignancies of hollow-tube organs:
It may be represented by various macroscopic types such as:
Stricture
Ulcerating
Fungating mass
Microscopic features are similar to the squamous cells carcinoma:
Histology shows:
Keratin formation
Intercellular bridges
Oesophageal Squamous Cells Carcinoma
Outline the spread of Oesophageal Squamous Cells Carcinoma
Spread of Oesophageal Squamous Cells Carcinoma refers to how the carcinoma can metastasize
Oesophageal Squamous Cells Carcinoma can metastasize by:
Local spread
Lymphatic System
Haematogenously
Local Spread can be:
Transmural through oesophageal wall
Longitudinal through the submucosal lymphatics
Lymphatic spread may involve:
Oesophageal or Paratracheal Lymph Nodes
Hematogenous spread may results in metastasize to the:
Liver
Lungs or Adrenal Glands
Complications of Oesophageal Squamous Cell Carcinoma
List the Complications of Oesophageal Squamous Cell Carcinoma
The complications Oesophageal Squamous Cells Carcinoma are those of malignancy in a hollow-tube organ:
They may include:
Obstruction
Dysphagia
Aspiration pneumonia
Infection
Cachexia
Haemorrhage
Oesophageal rupture of Tracheoesophageal fistula
Adenocarcinoma
Describe the Pathogenesis of Oesophageal Adenocarcinoma
Oesophageal Adenocarcinoma is more prevalent in people with Western diets
Gastroesophageal reflux may lead to intestinal metaplasia of the lower oesophagus and subsequent Dysplasia
Morphology of Oesophageal Adenocarcinoma
Outline the morphology Oesophageal Adenocarcinoma
Oesophageal Adenocarcinoma usually involves the Distal oesophagus
Macroscopic Features of Oesophageal Adenocarcinoma:
Oesophageal adenocarcinoma occur at the gastroesophageal junction
Microscopic features are similar to those of the other Adenocarcinomas
Histology shows:
Glands
Mucin production
Pathology of the Stomach
Hypertrophic Pyloric Stenosis
Outline Hypertrophic Pyloric Stenosis
Hypertrophic Pyloric Stenosis refers to the gastric outlet obstruction caused by the hypertrophy of the pyloric muscles
As a result, no food can pass through the occluded Pyloric muscle at the Gastro-Duodenal junction
The typical clinical history is that of a 3 week old male baby who presents with projectile vomiting.
Gastritis
Outline Gastritis
Gastritis is typically divided into:
Acute (Erosive) gastritis
Chronic Gastritis
Acute (Erosive) Gastritis
Outline the Aetiology of Acute (Erosive) Gastritis
Acute Gastritis can be caused by an ingested substance or something affecting the patient's whole body
These may be:
Local Mucosal factors:
Alcohol
Drugs such as NSAIDs
General factors:
Shock due to severe burns
Raised intracranial pressure
Outline the Pathogenesis for Acute (Erosive) Gastritis
In general the pathogenesis of Acute Gastritis is due to an imbalance favouring the factors that cause injury over the protective factors
An injury to the mucosal barrier causes H+ ions to diffuse back into the epithelium
This stimulates Mast Cells to release Histamine, which causes inflammation
Poor circulation causes a decrease in cell production with a loss of epithelial integrity
Morphology of the Acute Gastritis
Outline the macroscopic features of Acute Gastritis
Macroscopic features of Acute gastritis include:
Oedematous mucosa
Haemorrhages
Erosions
Stress ulcers
The image shows Acute (erosive) Gastritis
Where erosions in the stomach have the macroscopic appearance of small dark areas of haemorrhage
Chronic Gastritis
Outline the Aetiopathogenesis of Chronic Gastritis
There are 3 main causes of Chronic Gastritis:
Helicobacter pylori associated Gastritis
Helicobacter pylori is a type of bacteria that enters the body and lives in the digestive tract
Autoimmune Gastritis
Reactive Gastritis
Helicobacter Pylori Associated Gastritis
Outline Helicobacter Pylori Associated Gastritis
Helicobacter Pylori infection affects the mucosa of the Antrum
Helicobacter Pylori Infection causes gland-associated neutrophils in the Pyloric Antrum
It can result in Active Chronic Gastritis
Describe the microscopic features of Helicobacter Pylori Associated Gastritis
Microscopic features of Helicobacter Pylori Gastritis:
Heavy chronic inflammation in the gastric mucosa with Lymphoid aggregates
Seagull-shaped Helicobacter Pylori bacteria in the gastric pit on a Giemsa stain
Autoimmune Gastritis
Outline Autoimmune Gastritis
Autoimmune gastritis causes atrophy of the Gastric Parietal cells located in the fundus and body of the stomach
This results in:
A Chronic Atrophic Gastritis affecting the gastric body
Reduced acid production known as Hypochlorhydria, which results in increased Gastrin Secretion known as Hypergastrinaemia from the Antrum of the stomach
Antibodies to intrinsic factor result in a malabsorption of Vitamin B12 with Megaloblastic anaemia
Morphology of Autoimmune Gastritis
Outline the Morphological features of Autoimmune Gastritis
Histologically Autoimmune Gastritis has the following features:
Chronic inflammation in the mucosa
Gland atrophy which decreases mucosal thickness
Intestinal metaplasia
Eventually, there will be a complete loss f Chief cells and Parietal cells in the body and fundus of the stomach, which replacement by Intestinal Goblet-cells
Reactive Gastritis
Outline Reactive Gastritis
Reactive Gastritis shows less inflammation that Helicobacter Pylori Infection and Autoimmune Gastritis
Reactive Gastritis is due to the reflux of bile-containing duodenal fluid into the Lower Stomach due to Pyloric Sphincter incompetence
It is associated with prolonged NSAIDs use causing surface epithelial damage
Peptic Ulceration
Outline Peptic Ulceration
Peptic Ulcers only occur in the Gastric Antrum and Duodenum
Peptic Ulceration is a result of an imbalance between Acid or Pepsin attack and Mucosal Resistance to digestion
There are two types of Ulcers:
Gastric Ulcer which is due to a decreased Mucosal resistance to digestion
Duodenal Ulcer which is due to an increase in Acid secretion
Gastric Ulcer
Outline the Aetiology of Gastric Ulcers
Gastric ulcers are generally due to a decrease in mucosal resistance to digestion
A breach of mucosal resistance is most predominant in gastric ulcers
This may be due to:
Helicobacter pyloric bacteria
NSAIDs
Smoking or Alcohol
Benign Peptic Ulcer vs Malignant Gastric Adenocarcinoma
Outline the macroscopic distinction between Benign Gastric Ulcers & Malignant Gastric Ulcers
Benign Ulcers:
Punched out
Located in the Antrum, lesser curvature
Small
Small Soft lymph Nodes
Vessel in smooth base
Radial mucosal folds
Malignant Ulcers:
Not punched out
Located int he Greater curvature
Large
Large, Firm Lymph Nodes
ALL gastric ulcers must be biopsied to exclude malignancy
An ulcer in the stomach could be benign peptic ulcer, or it could be an ulcerated gastric adenocarcinoma
They do not change from one ti the other over time
It is not possible to say that a gastric ulcer is definitely benign based on its macroscopic features
If the Macroscopic features of a Gastric Ulcer are aligned to the features of a malignant ulcer, it would be suspicious that it represents an ulcerated gastric adenocarcinoma
Morphology of Gastric Ulcers
Describe the Morphology of Gastric Ulcers
Macroscopic features of a benign gastric ulcer:
Ulcer is punched out with straight edges
Radiating mucosal folds surround the ulcer
Microscopic features of a benign gastric ulcer:
Extensive fibrosis in the ulcer bed, but no evidence of adenocarcinoma
Complications of Gastric Ulcers
List the Complications of Gastric Ulcers
The complications are those of an ulcer in a hollow-tube organ:
Penetration
Perforation
Haemorrhages
Fibrosis/Obstruction
Duodenal Ulcers
Outline Duodenal Ulcers
Duodenal Ulcers are due to an excessive increase in acid secretion from the stomach
This may be associated with:
Helicobacter pylori associated gastritis
Gastrin producing endocrine tumour
An image of a Duodenal Ulcer visualized through an endoscope
Gastric Carcinoma
List the Risk Factors of Gastric Adenocarcinoma
Risk factors of Gastric Adenocarcinoma:
Helicobacter pylori infection
Helicobacter pylori infection which leads to Chronic Atrophic Gastritis, which results in Intestinal Metaplasia and subsequent Dysplasia
Nitrosamines in smoked or salted foods
Adenomatous polyps
Autoimmune gastritis
Gastric cancer in families
Morphology of Gastric Adenocarcinoma
Describe the Morphology of Gastric Adenocarcinoma
Macroscopic appearance is that of malignancy in a hollow-tube organ:
Polypoid/Fungating
Ulcerating (Raised, rolled edges)
Annular constricting
Diffusely infiltrating type which has the appearance of an old-fashioned leather bottle used to carry liquids
Microscopic appearance are classified according to the Lauren Classification:
Intestinal type: shows gland formation
Diffuse type: shows Signet Ring Cells
The macroscopic features of gastric carcinoma
Fungating carcinoma, with an irregular outline
Raised rolled ages and central ulceration
The microscopic features of gastric carcinoma
Intestinal type adenocarcinoma is composed of large glands
Diffuse type adenocarcinoma is composed of single-lying cells
With intra-cellular mucin droplets which compress the nuclei to the side of the cell
So that the individual malignant cells look like signet-rings with a central hole.
Spread of Gastric Adenocarcinoma
Outline the spread of Gastric Adenocarcinoma
Spread refers to how Gastric Adenocarcinoma metastasizes
Gastric Adenocarcinoma can spread through:
Local spread
Transmural through the wall of the stomach
Lymphatic system
To the Lymph Nodes lining greater and lesser curvatures
Hematogenous spread
Blood spread to the Liver and lungs
Transcoelomic spread
Through the Peritoneal cavity
Complications of Gastric Adenocarcinoma
List the Complications of Gastric Adenocarcinoma
The complications are those of a malignancy in a hollow-tube organ
They include:
Haemorrhage
Obstruction
Penetration of adjacent organs
Rupture
Cachexia
