GIT

Disorders of the Esophagus GIT-lect-2

TUCOM-DEP. OF PATHOLOGY

Congenital anomalies of the esophagus

1-Atresia and fistula .Uncommon, may be incompatible with life. .segment of esophagus replaced by thin cord. .may be connected to trachea, A,B,C,D&E. May be associated with heart anomalies. .Aspiration and suffocation, pneumonia, and fluid and electrolyte imbalance. 2-Stenosis, webs and rings: .webs in females < 40 years, ID anemia, dysphagia. Plummer Vinson syndrome , SCC.

FIGURE 11-1 Types of tracheoesophageal anomalies and their relative frequencies.

Disruption of the normal physiological events of oropharyngeal or esophageal swallowing results in one of the cardinal symptoms of disease = DYSPHAGIA . Dysphagia can be categorized as oropharyngeal or esophageal depending on which phase is involved. Dysphagia can be caused by 2 general types of disease processes: 1. Structural/mechanical abnormalities. 2. Neuromuscular (motor) abnormalities.

Causes of Esophageal Dysphagia

Mechanical disorders 85-90% Peptic stricture: Slowly progressive Chronic heartburn Esophageal cancer: Rapidly progressive Age > 50 years Other Motor disorders 10-15% Achalasia Esophageal spasm Scleroderma Other

Achalasia

Formerly known as “cardiospasm”Mechanism:Absent esophageal body peristalsisIncomplete LES relaxationLES hypertensionCauses in USA cases:Idiopathic or primary95%+Neoplasm< 5%Other (e.g. amyloidosis)< 1%Causes in South American cases:Chagas disease (trypansoma cruzii)

Primary Achalasia

Pathology Loss of ganglion cells in myenteric plexus of esophagus. Degenerative changes of the dorsal motor nucleus in the medulla in some patients. Etiology - unknown, ? infectious Clinical features Gradually progressive dysphagia to solids & liquids. Chest pain in some patients. Nocturnal aspiration & weight loss may occur.

Achalasia

Diagnosis Barium esophagogram Esophageal manometry Endoscopy (to exclude underlying neoplasm)

Achalasia

Hiatal Hernia
It means separation of the diaphragmatic crura and widening of the space between the muscular crura and the esophagus. Two types: 1- Sliding: most common 95% (axial) due to protrusion of the stomach above the diaphragm. 2- Para-esophageal (non axial) separate portion of the stomach enter the thorax. Cause unknown.

Hiatal Hernia

The hernia prevents the food from moving normally along the digestive tract. Food moves back into the esophagus, creating a burning sensation (heartburn), and sometimes food will be regurgitated into the mouth. Can be complicated by strangulation, obstruction, ulceration, bleeding and perforation.

Hiatal Hernia

Lacerations (Mallory-Weiss Syndrome)
Definition
Longitudinal tears in the esophagus at the EG junction
Cause
Severe retching or vomiting.
Clinical
Upper GI bleeding
Morphology
Tear in mucosa, perforation or esophageal rupture

DIVERTICULA

1- Proximal: The diverticula appearing in the upper portion of the esophagus (Zenker's diverticula) are the result of out pouching of esophageal mucosa at points of weakness in the wall of the esophagus at the junction with the pharynx. They are more properly designated as pharyngoesophageal and are classified as pulsion diverticula. They occur at this point because of the relationship between the inferior constrictor muscle and the obliquely passing fibers of the cricopharyngeal muscles as they descend on the posterior wall of the esophagus to become longitudinal. 2- Distal: In the lower third of the esophagus and in the region of the hilum of the lung, inflammatory lymph nodes (usually tuberculous) can become firmly attached to the esophagus and produce traction diverticula.

Esophageal Diverticulum

varices
Occur due to portal hypertension as a result of formation of collateral bypass channels between portal system and caval system, along the coronary veins of the stomach into the plexus of esophageal subepithelial and submucosal veins into the azygos vein. Gross: turtuous dilated veins in submucosa of distal esophagus and proximal stomach, ero, inf. Rupture causes massive bleeding. May die from bleeding or hepatic coma (blood digestion).

ESOPHAGITIS

Aetiology: 1- RE. 2- prolonged intubation. 3- irritants. 4- Cytotoxic, radiation. 5- Viral and fungal infection. 6- uremia and hypothyroidism.

Gross and microscopy:

Hyperemia, inflammation, ulceration and granulation tissue. MIC: 1- eosinophilic infiltration & neutrophils. 2- basal cell hyperplasia. 3- elongation of the lamina properia papillae.

pathogenesis

1- decreased efficacy of esophageal anti-reflux mechanism. 2- Inadequate or slowed esophageal clearance of refluxed material. 3- presence of sliding hiatal hernia. 4- increased gastric volume. 5- reduction in the reparative capacity of the esophageal mucosa by protracted exposure to gastric juices.


Severe, long term effects
Gastrointestinal bleeding.Stricture.Barrett’s esophagusThere is columnar epithelium in the esophagus where stratified squamous epithelium should beAnd its risk = Cancer .

BARRETTS ESOPAHGUS

BE
.11 % of symptomatic reflux disease. .Pathogenesis: prolonged recurrent GER leads to inflammation, ulceration of Sq.ep. Which heal by re epithelialization and in growth of pluripotent stem cells, which in acidic microenvironment differentiate into gastric cells or intestinal which is more resistant to acids.

Barrett

Barrett esophagus
Cause →Clinical → Long standing GE reflux. Heart burn, pain
Morphology → Gross and microscopy: columnar metaplasia
Complication →The risk to get Esophageal adenocarcinom Adenocarcinoma is 0.5% per year


RE


BE
Esophagus Squamous epithelium
Stomach Columnar (adeno) epithelium
Z-line
Columnar metaplasia
Gastric
Intestinal

BE & CA

Barium Swallow:
Narrowing Little entry into stomach

Esophageal Biopsy:

Stratified Squamous epithelium – normalTumor tissue below.

Esophageal Biopsy:

Stratified Squamous epithelium – normalTumor tissue below.

Esophageal Biopsy:

Stratified Squamous epithelium – normalTumor tissue below.

Esophageal Biopsy:

Pleomorphic cells with bizarre nuclei. Gland formation Note signet ring form of tumor cells



OTHER ESOPHAGEAL TUMORS
BENIGN : leiomyoma, fibroma, lipoma, hemangioma, neurofibroma. MALIGNANT: 1- SCC. 2- UNDIFFERENTIATED. 3- CARCINOID. 4- MALIGNANT MELANOMA.

SQUAMOUS CELL CARCINOMAAetiology:1- vit A and C def.2- Alcohol and tobacco.3- esophagitis and achalasia.4- high content of nitrites in diet.5- fungal infection. 6- HPV might play an etiologic role in esophageal carcinogenesis either by producing carcinogens or promoters or by acting directly on the host cells.

Morphologic features and local spread  Squamous cell carcinoma can occur in any portion of the esophagus but is most common in the middle and then lower thirds in areas of normal anatomic constrictions. Grossly, the tumor usually is circumferential, often ulcerated, with sharply demarcated margins. Polypoid forms occur, but are much less common than in adenocarcinoma. On cut section, a grayish white tumor is seen to invade part or all of the muscular wall, from which it may extend into the surrounding soft tissues and trachea Intraluminal growth also occurs and may eventually lead to total obstruction. Distally located tumors often invade the stomach.

Esophageal Carcinoma