Pathology of gastrointestinal tract I - Esophagus - Stomach MUDr. Helena Skálová
Esophagus • 25 cm
Wikibooks
Inborn defects • Atresia • Tracheoesophageal fistula
Robbins and Contran Pathologic Basis of Disease, 7th edition
Motoric dysfunction of esophagus • -
Achalasia: loss of cells in plexus myentericus loss of peristalsis inability od lower eosphageal sphincter to relax - megaesophagus
• Hiatal hernia: - widening of hiatus diaphragmaticus - displacement of GE junction and part of stomach to dorsal mediastinum - sliding, paraesophageal, mixed
Robbins and Contran Pathologic Basis of Disease, 7th edition
Motoric dysfunction of esophagus • Diverticules: - Zenker – FE junction - tractional – postinflammatory fixation to LN - epiphrenic – defective coordination of peristalsis and relaxation of sphincter
• Mallory-Weiss syndrome: - laceration of distal esophagus and GE junction - risk of bleeding, rarely perforation - after strong vomiting
Robbins and Contran Pathologic Basis of Disease, 7th edition
Esophageal varices • Portal hypertenzion (90% pacients with cirrhosis, e.g. alcoholic) • Portocaval anastomoses → varices in submucosa of terminal esophagus
• Asymptomatic → rupture → massive hematemesis • 40-50% mortality in each episode • 50% rebleeding • Therapy: varix sclerotization, baloon tamponade
Esophagitis • 5% adult population Etiology: - Gastroesophageal reflux disease - Consumption of strong iritants (acids, lyes, alcohol + smoking, hot liquids) - Infection – immunosupressed pacients (HS, CMV, candida, aspergilus)
Reflux esophagitis (= gastroesophageal reflux disease) • Reflux of acidic gastric content into distal esophagus over insufficient lower sphincter - decreased tonus of the sphincter (pregnancy, calming drugs alcohol + smoking) - sliding hiatal hernia • Adults > 40 y.o., children • Symptoms: heart burn (chest pain), dysphagia, regurgitation of acidic gastric content → cough • Micro: chronic inflammation in distal esophagus, Barrett esophagus
Barrett esophagus • 10% pacients with longterm symptomatic GE reflux • 40-60 years old, white men • Response to longterm irritation → intestinal metaplazia • Precancerosis: Dysplazia → adenocarcinoma (30-40x higher risk)
Tumors of esophagus Benign
Malignant
• Leiomyoma
• Squamocellular carcinoma
• Fibroma, lipoma, hemangioma … • Squamocellular papiloma
• Adenocarcinoma Prognosis: bad, high mortality
Gross: exophytic, flat, ulcerated Symptoms - late: dysfagia, obstruction, bleeding, weight loss
Adenocarcinoma • Carcinoma of distal esophagus in 10% pacients with Barrett esophagus • Symptoms include heart burn • Median 60 y.o., white men • Higher incidence: developed countries
• Micro: glandular mucous producing intestinal-type carcinoma • Invasion to stomach, mediastinum • Metastases in regional LN
Sqamocellular carcinoma • Whole esophagus, mainly upper 2/3 • Adults, > 50 y.o., men • Higher incidence: developing countries
• RF: alcohol, smoking • Invasion into surrounding structures (trachea, aorta, mediastinum, pericardium …) • Metastases in regional LN
Stomach
Gastritis = inflammation of gastric mucosa Symptoms: - dyspepsia of upper type, pain in epigastrium, nausea, vomiting, haematemesis, melaena - chronic often asymptomatic
Histological evaluation necessary 2 types: - Acute (neutrophils, haemorrhage, erosions) - Chronic (lymocytes, plasma cells + neutrophils in acute relaps)
Acute gastritis Haemorrhagic, erosive -
Risk factors - etiology: NSAID (Aspirin) Alcohol, smoking Acid burn (suicide attempt) Stress (shock, trauma, burns, surgery, sepsis)
Complications: haemoptysis (also massive), melaena Common disease 25% pacients using aspirin daily (rheumatoid arthritis) Gastropathy – irritation, erosions or mucosal bleeding without inflammation, may precede gastritis
Chronic gastritis Atrophy, hypertrophy Intestinal metaplazia Dysplazia RF for gastric cancer -
Etiology: Helicobacter pylori - B Autoimmune - A Toxic (alcohol, smoking) - C
Helicobacter pylori Nonsporulating Gram- rod • 1983 Campylobacter pyloridis • -
Specialization for life in stomach: Flagellum Ureasis (urea → CO₂ + NH₃) Expression of bacterial adhesins Expression of bacterial toxins → peptic ulcer
• Antral gastritis, ↑ secretion of HCl → peptic ulcer • Pangastritis, ↓ secretion of HCl, RF for ca • Association: - chronic gastritis, peptic ulcer - gastric carcinoma and lymphoma (MALT) • Therapy: antibiotics, inhibitors of proton pump
Autoimmune gastritis • ‹ 10% gastritides • Autoantibodies angainst parietal cells (e.g. receptor for gastrin, intrinsic factor) • Destruction of glands, atrophy of mucosa → ↓ production of HCl and intrinsic factor
• Malabsorption of vitamin B12 • -
Pernicious anemia: megaloblastic anemia demyelinization of dorsolateral tracts (motoric and senzoric) Hunter glossitis
• RF for carcinoma, carcinoid
Peptic ulcer Gastroduodenal ulcer disease • Etiology: H. pylori, ischemia, NSAID, alcoholic liver cirrhosis • H. pylori: 100% duodenal, 70% gastric (ulcer in 10-20% infected patients) • Chronic, solitary lesion, relapsing, spontaneously healing • Duodenum, antrum and lesser curvature (↑ HCl)
• Adults, more men • Symptoms: - Pain 1-3 hrs after meal and in the night, relief after meal - Nausea, vomiting, flatulence, weight loss • Dif. dg.: CARCINOMA!!! • Zollinger-Ellison syndrome – gastrinoma (NET usually in pancreas, duodenum)
Acute ulcer • NSAID • Stress ulcers – shock • Pathogenesis uncertain, role of ischemia
Complications of gastric ulcer • Bleeding - 15-20% pacients, 1/4 †
• Perforation, penetration - 5% pacients, 2/3 † • Stenosis by edema and strictures - 2% pacients - pylorus, duodenum
Tumors of stomach Benign
Adenoma Leiomyoma
Polyps
• Hyperplastic polyp • Fundic gland polyp
Malignant
• • • •
Carcinoma (93%) Lymphoma (4%) GIST (2%) NET = carcinoid (3%)
Stomach carcinoma One of the most frequent worldwide (↑↑↑Japan) High mortality, decrease from 60‘ (endoscopy) M:W = 2:1 RF: H. pylori (5-6x) – chronic gastritis, diet Symptoms - late: ↓ weight, pain, anorexia, vomiting, haemorrhage, anemia 2 main histological types: - Intestinal (resambles intestinal adenocarcinoma) - Diffuse (poorly differenciated, often with signet-ring cells)
!
Stomach carcinoma Early Advanced
Local invasion: duodenum, pancreas, retroperitoneum Metastases: region and distant LN (Virchowov), peritoneal spread, liver, lungs, ovaries (Krukenberg tumor)
Other malignant gastric tumors -
Lymphoma (MALToma, low grade) H. pylori (regression after atb elimination) mucosa, submucosa symptoms: nonspecific (nausea, dyspepsia)
-
GIST Cajal cells solitary, multiple 30% malignant (abdominal spread, distatnt metastases)
Neuroendocrine tumor = carcinoid
Stomach NET (neuroendocrine tumor) • Neuroendocrine tumor (NET) • Neuroendocrine carcinoma (NEC) Predisposition: • Autoimmune chronic atrophic gastritis • MEN1 (syndrome of multiple endocrine neoplasia) • Zollinger-Ellison syndrome – gastrinoma (NET usually in pancreas, duodenum) • Solitary, multiple • Small tumor • Growth in deep LPM and submucosa, covered by mucosa • May produce serotonin, histamin, ATCH, gastrin …
Bleeding into gastrointestinal tract • Hematemesis: - vomiting of blood - from upper GIT (oral cavity, esophagus, stomach) • Melaena: - digested (black) blood in stools - from upper GIT (oral cavity, esophagus, stomach) • Enterorrhagia: - fresh (red) blood in stools - from lower GIT (intestines, anus) • Other symptom: anaemia
Differential diagnosis: Hematemesis and melaena Oesophagus -Varices -Reflux oesofagitis -Oesophageal carcinoma -Sy Mallory-Weiss -Rupture of aortal aneurysm -Acid burns -Foreign body
Stomach -Varices of gastric carcia -Gastritis (aspirin, alcohol) -Ulceration (incl. Zollinger-Ellison sy) -Stomach carcinoma -Vascular malformation -Complication of endoscopy
Duodenum -Ulceration -Tumor -M. Crohn -Penetration of bile stone into duodenum -Acute hemorrhagic-necrotizing pancreatitis
Other: -Hemorrhagic diathesis -Trauma -Hemoptysis -Bleeding from oral cavity
Differential diagnosis: Enterorrhagia
• • • • • •
Hemorrhoidal varices Diverticulosis Ulcerative colitis, Crohn disease Bacterial enterocolitis Carcinoma, larger adenoma Iatrogenous (after polypectomy, postradiation, NSAID …)
Summary • • -
Esophagitis: reflux → chronic inflammation → intestinal metaplasia → adenocarcinoma Esophageal tumors: adenocarcinoma, squamous carcinoma bad prognosis
• • -
Helicobacter pylori: chronic gastritis, peptic ulcer, stomach adenocarcinoma, lymphoma Stomach tumors: adenocarcinoma (intestinal, diffuse)
• Bleeding into GIT: - hematemesis, melaena, enterorrhagia, anaemia - upper, lower GIT, adjacent structures
