16. Upper GI pathology
Inflammatory infiltrate in acute vs chronic gastritis
*Acute*: - neutrophils + edema in lamina propria *Chronic*: - lymphocytes (if H. Pylori → neutrophils) - glandular mucosa atrophy, fibrosis, metaplasia
2 types of oesophageal cancer: - epidemiology - risk factors - location - prognosis
*Adenocarcinoma* - #1 in US - W>B - GERD, Barrett's - GE junction - poor *Squamous cell* - #1 in world - B>W - ETOH, smoking - mid-oesophagus - poor
2 types of gastric adenocarcinoma
*intestinal type* - gland formation - polyp/ulcer *Infiltrative type* - aka linitis plastica - lesion not localised to 1 place, diffuse spread thru wall - *signet ring cell* = infiltration of mucin+ cells
peptic ulcer (benign) vs adenocarcinoma (malignant)
*peptic ulcer*: - antrum - punched-out - smooth base - radiating gastric folds *Adenocarcinoma* - body/antrum - irregular edges - shaggy base - loss of normal folds
Gross appearance of infiltrative type of gastric adenocarcinoma
- "leather bottled stomach", no rugae - lesion not localised to 1 place, diffuse spread thru wall - linitis plastica
Pleomorphic adenoma
- #1 benign salivary gland tumor - firm, freely movable mass, normal skin on top - encapsulated, tan-white - often recur
Mucoepidermoid carcinoma
- #1 malignant salivary gland tumor - low-grade (slow, painless) or high-grade (rapidly enlarging, painful) - unencapsulated, infiltrative to surrounding tissue - skin on top discoloured
Autoimmune Sialadenitis
- *Sjogren's disease*: destruction of parenchymal cells -* infiltrates of lymphocytes + plasma cells* - ↑ incidence of lymphoma - also affects lacrimal glands
Criteria for Barrett's Esophagus (2)
- *intestinal metaplasia*: column epithelial goblet cells (from chronic inflammation of at GE junction) - replaces the squamous epithelium above GEJ
Gastric Lymphoma/MALToma
- *lymphoepithelial lesion* from lymphocytes invading + destroying glands - how it's malignant from *density* +* extends* thru lamina propria
Cause of chronic gastritis
- H. Pylori (80%) - autoimmune - environment (diet)
Gastric adenocarcinoma: - geography - risk factors - prognosis
- Japan, China, Chile - chronic gastritis, polyps, ↑ nitrosamines from smoked meat, ↓ fruits/veggies - if entirely resectable >90% survival, if advanced <15%
Causes of acute gastritis
- NSAIDs - aspirin - smoking - ETOH - steroids - stress - hypertension/shock
Major salivary gland
- Parotid (serous) - Submandibular (serous > mucinous) - sublingual (mucinous > serous)
Metastases of gastric adenocarcinoma
- Virchow's node (L supraclavicular LN) - Krukrmberg's tumor (ovarian)
How does hiatal hernia → GERD?
- alters function of LES → reflux gastric contents
Autoimmune metaplastic atrophic gastritis: - mechanism - location
- autoantibodies to parietal cells (90%), intrinsic factor (60%) - ↓ acid + pernicious anemia - in body/fundus
Infectious Sialadenitis cause
- bacterial: Staph. Aureus, Strep. Viridans → obstruction - virus (kids): mumps (Paramucoviridae)
Gastric polyps
- benign (inflammatory) 75% - dysplastic (gastric gastritis) - malignant (adenocarcinoma)
Pathology of mucoepidermoid carcinoma
- duct/cyst-like spaces - epidermoid, intermediate + mucous cells
Location of H. Pylori peptic ulcers
- duodenum > stomach (antrum)
Reactive changes in esophagus after GERD
- enlarged, darker cells - elongation of papillae
Esophageall adenocarcinoma
- forms glands - at GE junction
Complications of peptic ulcer disease
- haemorrhage (+ iron-deficiency anaemia) - perforation - luminal stenosis from scarring
Oesophageal varices: - symptoms - causes
- hematemesis - cirrhosis of liver, portal HTN
Menetrier's disease: - definition - epidemiology - symptoms
- hypertrophic gastropathy (hypertrophy of mucous cells + rugae from ↑TGF-a) - M>F - 40-60 - ↓ albuminemia, atrophy of parietal cells - predisposes to cancer
Main causes of Esophagitis
- infection (Herpes, CMV; Candida in immunosuppressed) - chemical irritants (lye) - reflux of gastric juice (ulcers → metaplasia)
What are 2 diseases that can cause linitis plastica?
- infiltrative type gastric adenoma - gastric lymphoma
Sialadenitis
- inflammation of a salivary gland - can be infectious or autoimmune
Oesophageal web associations
- iron-deficiency - Pluummer-Vinson syndrome - F>M, ↑ cancer risk
Oesophageal atresia
- lack of lumen - babies vomit ingested milk - requires repair for survival
Gastrointestinal Stromal Tumor (GIST): - definition - location - treatment
- malignant - from stromal tissue in GI tract - stomach>small bowel - Rx: Imatinib
Where in stomach do you find: - mucous cells - parietal cells (acid) - chief cells (pepsin) - G cells (gastrin)
- mucous: cardia + antrum - parietal: fundus - chief: fundus - G: antrum
Where do most salivary gland tumors occur?
- parotid gland - of epithelial origin (carcinoma) - 75% are benign
Most common salivary gland neoplasm: - benign - malignant
- pleomorphic adenoma - mucoepidermoid carcinoma
Histology of pleomorphic adenoma
- pleomorphic variability
Mallory Weiss Syndrome: - definition - location - risk factors
- small vessel laceration at gastroesophageal junction - alcoholics, history of severe vomiting
What lifestyles can ↓ tone of LES?
- smoking - caffeine - pregnancy
Achalasia: - definition - symptoms - causes
- spasm of LES with esophageal dilatation - dysphagia - idiopathic (also Chagas, cancer, amyloidosis, scleroderma)
Pathology of esophagitis
- spongiosis - immune cell infiltrate - basal cell hyperplasia
Definitive landmarks of tubular esphagus
- squamous duct - submucosal mucous glands
Squamous cell carcinoma
- swirled growth - keratin pearls - nests of cells - mid-esophagus
Epidemiology of salivary gland cancer
- women > men - all ages, peak 60-70s
2 types of hiatal hernia
1. *Sliding* - very common, slides back + forth 2. *Paraesophageal* - loop of cardia gets stuck, compresses esophagus - risk of infarct (both displacememtnof gastric cardia from abdominal cavity thru diaphragmatic hiatus, relaxed crura)
What conditions are associated with these: 1. cancer + neuroendocrine tumor = ? 2. cancer + MALT lymphoma = ?
1. autoimmune metaplastic atrophic gastritis 2. H. Pylori
4 levels of acute/chronic inflammation of gastric ulcer
1. necrosis + neutrophils 2. neutrophils 3. granulation tissue, lymphocytes 4. fibrosis/scarring
erosion vs ulcer
Erosion: only involves mucosa, punch holes, multiple Ulcer: into submucosa, 1 deep hole
What is required for Barrett's esophagus diagnosis?
Intestinal metaplasia with goblet cells
serous vs mucinous acini appearance
Mucinous: cytoplasm clear, pushes nucleus to the side Serous: darker, central nucleus
Stain used for H. Pylori
Warthin-starry stain
Zenker's vs. traction diverticula
Zenker's: pulsion, thru weak muscle Traction: pull from adhesions
Types of upper + lower esophageal sphincters
both physiologic → just nerves + muscle contractions
Pyloric stenosis
congenital: - M>F - projectile vomiting acquired: - from PUD
How does grading of mucoepidermoid carcinoma work?
correlates with abundance of mucous cells: - many mucous cells → low-grade - few mucous cells → high-grade
Most common cause of reflux esophagitis
hiatal hernia
Signet cells
in infiltrative type of gastric carcinoma
what tissue is GIST (GI stromal tumor) from?
interstitial cells of cajal → stromal tissue (CT)
Goblet cells are sign of what epithelium?
intestinal or intestinal metaplasia
low vs high grade dysplasia of esophagus
low-grade: - enlarged elongated nuclei high-grade: - enlarged nuclei - loss of polarity - high N/C ratio - mitoses - cellular pleomorphism
Major vs minor salivary gland neoplasms
major - more likely benign minor - more likely malignant
Schatzki's ring vs oesophageal web
ring: circumferential, lower oesophagus web: partial circumferential, upper esophagus
Gross appearance of Barrett's esophagus
tongue-like, salmon-colored protrusions into esophagus
cricopharyngeaus
upper oesophageal sphincter (15-18 cm from incisors)
