Gi #11: Pathology Of The Esophagus

Front 1

Describe the normal esophageal path seen on gross level and on histology.

Back 1

Gross: squamous esophagus --z-line (squamocolumnar junction) -- columnar stomach lining.

Histology: Mucosa (non-keratinized stratified squamous, LP, and muscularis mucosa)--Submucosa with mucous glands & Meisners-- then muscularis externa (IC, OL). Upper 1/3rd = skeletal, Lower 2/3 = smooth m.

*there is NO SEROSA in the esophagus (just some adventitia)

Front 2

Which type of esophageal atresia is the most common?

What is the typical clinical scenario that would lead you to suspect this?

Back 2

Type C (at tracheal bifurcation). Atresia = abnormal closure of esophagus (ends in a blind end pouch).

Seen in newborns with aspiration, recurrent pneumonia, or regurgitation after feeding. Associated with congenital anomalies in other systems as well (heart, GU, GI).

Front 3

What is the most common type of hiatal hernia?

What is a common presenting symptom in these patients? Which type of Hernia would produce less symptomatology?

Back 3

Sliding >> Paraesophageal hernia

Decreased tone of LES --> GERD, heartburn, bleeding, ulceration and perforation. Paraesophageal has less symptoms because diaphragm still retains some pressure on LES.

Front 4

What do you see on the bottom endoscopic images?

What are some causes for this condition?

Back 4

This is Reflux esophagitis (top = normal, bottom= hyperemia & erosion). From acid reflux.

Pathogenesis = multifactorial. Typically incompetent LES , hiatal hernias, obesity, pregnancy, alcohol, tobacco, etc.

Front 5

What is seen on Histology in reflux esophagitis?

Back 5

1) elongation of LP papillae
2) Basal cell hyperplasia
3) intraepithelial eosinophils and neutrophils (seen above)

Front 6

What part of the esophagus would this biopsy typically come from?

What demographic is often affected? What is the treatment?

Back 6

Eosinophilic Esophagitis (typically at mid esophagus, rather than G-E junction). Identify eosinophilic microabscess.

Often seen in children who have atopy and GERD like sxs. Treat with dietary restriction and steroid inhalation.

Front 7

This condition is a complication of _______. What does the salmon pink colored part look like on histology?

Back 7

Barrett's esophagus- complication of longstanding GERD.

Pink tongues= replacement of stratified squamous epithelium with intestinal metaplasia (glandular mucosa is thought to be protective).

Front 8

This sample was taken from the esophagus. What is concerning about it?

What is the major sequelae we are concerned about?

Back 8

There are pale blue goblet cells and gland-like formation. This is intestinal metaplasia in the esophagus.

Concerned about dysplasia --> Adenocarcinoma. (also worried about ulceration, bleeding, strictures)

Front 9

What signs of dysplasia do you see on the image on the right?

Describe the progression histologically of barrett's esophagus to adenocarcinoma.

Back 9

Dysplasia = neoplastic changes. Hyperchromasia, high N:C ratio, very little cytoplasm. Crowding/overlapping of cells.

Columnar metaplasia --> intestinal metaplasia --> low grade dysplasia --> high grade dysplasia --> adenocarcinoma

*above = high grade dypslasia (ugly nuclei, nuclear atypia, architectural irregularity, back to back glands)

Front 10

Infectious Esophagitis is mainly seen in what type of patients?

What are some common presenting features?

Back 10

Immunocompromised (chemo, HIV), or Elderly.

Presentation- odynophagia, dysphagia.

Front 11

This is a biopsy from someone's esophagus. What condition would you suspect and how would it look on high powered examination?

Back 11

HSV (herpes) infection or reactivation in nerves.

Note the ulcer formation here and normal mucosa of esophagus on the right. Classic finding = intranuclear viral inclusions (cowdry type A). You can see molding of nuclei and clear halo. You also see chromatin margination.

Front 12

This is an image of an esophagus in an HIV+ person with odynophagia. The causative agent infects what type of cells?

Back 12

HSV Gross pathology= shallow vesicles and ulcers.

Infects the epithelial cells.

Front 13

What is the causative agent of this patients odynophagia?

What cells does it infect?

Back 13

CMV (usually in immunocompromised patients). Gross histology look like herpes (punched out mucosal ulcers).

Virus infects ENDOTHELIAL cells (also has intranuclear inclusions with clear halo. Does not have margination of chromatin. Can be confirmed with immunohitstochemistry).

Front 14

This patient undergoes an endoscopy for pain with swallowing after a course of antibiotics and you find white plaques on an erythematous mucosa.

What would you see on histology? Would you attempt to do any special staining?

Back 14

Candida esophagitis =most common cause of INFECTIOUS esophagitis. Candida albicans.

Candida = normal flora in GI so needs to show invasion. You see neutrophils at surface of squamous mucosa. Stain for PAS or GMS --> pseudohyphae.

Front 15

What are the two major types of Esophageal tumors? What type of tumor is shown here?

What age group/ gender is affected? What are some risk factors and molecular findings?

Back 15

Adenocarcinoma (50%) and Squamous Cell Carcinoma (50%)

This is adenocarcinoma. Typically M>F, white, 60y/o.
Barrett's esophagus, tobacco, obesity, p53, c-erb2 (HER2 neu), loss of p16/INKalpha.

Front 16

What are some histologic features that identify this condition?

How do you determine the prognosis of this condition?

Back 16

Adenocarcinoma of esophagus- Irregular, infiltrative glands (note- dysplasia does NOT invade).

Prognosis depends on tumor stage (depth of invasion) and mets. T1 = mucosa, best prognosis. T4 = invasion into adjacent organ (worst prognosis)

*the esophagus is NOT covered by serosa, so after muscularis propria, it can break through into another organ.

Front 17

What are the two types of cancers seen here?

Back 17

Both Squamous cell carcinoma (50% of esophageal cancer)-

Left = exophytic cancer
Right = ulcerating cancer

Front 18

What type of cancer is this (based on histology alone)?

What is prognosis in this cancer determined by?

Back 18

Squamous Cell carcinoma (note the keratin pearls). Prognosis depends on Tumor stage (but generally worse survival than adenocarcinoma).