16. Upper GI pathology

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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)


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