oesophagus congenital anomalies, motor dysfunction, gerd and tumours 28-5-2016
TRANSCRIPT
Pathology of Esophagus
T.Mathumithra
© 2008 Chettinad Hospital & Research Institute
OESOPHAGUS
• Motor dysfunction –acalasia cardia• Gastro-oesophageal reflux disease (GERD)• Barrett’s oesophagus• Tumours
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About THE OESOPHAGUS……..
There are 2 sphincters • UES: 3 cm segment at the
level of crico-pharyngeus muscle
• LES: 2 – 4 cm segment just proximal to GE junction25 cm
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ANATOMY OF THE OESOPHAGUS• It is lined throughout by
stratified squamous epithelium
• Most of oesophagus lacks serosa (infection and tumours spread early)
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PRINCIPAL SYMPTOMS OF OESOPHAGEAL DISORDERS• Heartburn (retro-sternal burning pain) primary symptom of gastro-esophageal reflux burning sensation that radiates up from the
stomach to the chest & throat. • Dysphagia • Odynophagia• Haematemesis
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SPECIAL DIAGNOSTIC PROCEDURES IN OESOPHAGEAL DISORDERS• Oesophagoscopy• Radiographic barium
studies
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OESOPHAGUS - MOTOR DISORDERS (ACHALASIA)
(1) aperistalsis, (2) incomplete relaxationof LES with swallowing &(3) ed resting tone of LES
Idiopathic - thought to be due to loss ofneurons containing NO & VIPChagas disease (Trypansoma cruzi) destruction of the myenteric plexus in the walls of esophagus
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In patients with portal hypertension (usually micronodular cirrhosis from chronic alcoholism or schistosomiasis ), the sub-mucosal esophageal veins become dilated (form varices). These varices are prone to bleed & cause death in ~ 40% of patients with advanced cirrhosis.
Oesophageal Varices
OESOPHAGITIS• Most common cause is gastro-esophageal reflux
disease (GERD or reflux oesophagitis)• Other causes:
• Ingestion of mucosal irritants; smoking etc.,• In immune deficient patients:
• Viral – CMV; Herpes simplex• Fungal – Candidiasis (thrush);
mucormycosis; aspergillosis.• Uraemic
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CAUSES OF GASTRO-OESOPHAGEAL REFLUX
1) Mechanically incompetent lower LESsed sphincter pressure
2) Inefficient clearance of refluxed gastric juice
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OESOPHAGITIS – GERD - PATHOGENESIS
• Decreased efficacy of anti-reflux mechanisms – CNS depressants – alcohol \ tobacco exposure
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OESOPHAGITIS – GERD
• adults over 40yrs
• Clinically – heart burn, dysphagia, regurgitation
• May develop stricture or Barrett oesophagus
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REFLUX OESOPHAGITIS• Presence of
inflammatory cells (eosinophils & neutrophils) in the squamous epithelium;
• Elongation of lamina propria;
• Basal zone hyperplasia
Normal oesophageal mucosa
Reflux oesophagitis
OESOPHAGITIS - BARRETT OESOPHAGUS
• Chronic GERD --glandular metaplasia of the lower oesophagus-- known as Barrett oesophagus
• 10% of GERD patients
• Consist of transformation of squamous epithelium into columnar epithelium with many goblet cell
• Adenoca risk (30-40 fold increase)
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BARRETT OESOPHAGUS• Two types:
• Long segment (>3cm)• Short segment (<3cm)
• Criteria for diagnosis• Endoscopic evidence of
columnar epithelial lining above GE junction
• Histologic evidence of intestinal metaplasia
Normal Oesophagus
Barrett Oesophagus
Dept of pathology, CHRI. 21
NEOPLASMS OF THE OESOPHAGUS
• Benign – mostly mesenchymal• Leiomyoma, fibroma, lipoma, neurofibroma,
lymphangioma etc
• Squamous papillomas – rare; When it is positive for HPV, it is called condyloma
• Malignant (6% of all malignancies of GIT)• Squamous cell carcinoma • Adenocarcinoma
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ADENOCARCINOMA OF THE OESOPHAGUS
• After 40 years of age; median age – 6th decade
• more often in men
• 10% of patients with Barrett oesophagus will develop adenocarcinomas arising from the Barrett epithelium
• Other risk factors: tobacco smoking; obesity
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ADENOCARCINOMA ARISING FROM BARRETT’S OESOPHAGUS• Usually located in distal
oesophagus
• Flat, raised or nodular lesions
• Infiltrating Malignant glands
• 5-year survival rate- <
20%
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SQUAMOUS CELL CARCINOMA - OESOPHAGUS• Most common primary malignant tumor of the esophagus
• accounts for 4% of all fatal cancers
• M:F = 4:1 (2 – 20:1)
• Most common in middle 1/3 of oesophagus
• Spreads early
• Rat tail appearance on barium swallow
• Poor prognosis
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FACTORS ASSOCIATED WITH SQUAMOUS CELL CARCINOMA OF OESOPHAGUSDietary • lack of vitamins (A,
B1) Nitrites/nitrosamines
Lifestyle• Alcohol consumption • Tobacco use• Urban environment
Oesophageal disorders• Long-standing
esophagitis• Achalasia• Plummer-Vinson
SyndromeGenetic
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SQUAMOUS CELL CARCINOMA - OESOPHAGUS• Clinical features
• Progressive dysphagia, usually not recognized until the lumen is 30-50% occluded
• Steady sub-sternal or back pain; hoarseness and cough
• Weight loss and anorexia; blood loss
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SQUAMOUS CELL CARCINOMA OESOPHAGUS
• 50% of carcinomas show p53 mutations• Location of tumours: 20% in upper third, 50% in
middle third & 30% in the lower third. • Gross patterns: polypoid (60%), flat (15%) ulcerated (25%)
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SQUAMOUS CELL CARCINOMA - OESOPHAGUS
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Thank you!
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