Pathology of the esophagus and the stomach

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Pathology of the esophagus and the stomach

• Dr. Zsolt Orosz

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Normal anatomy
appr. 25 cm in adults
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Atresia and related anomalies
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Heterotopia

• Heterotopic gastric mucosa
• Heterotopic pancreatic tissue
• Heterotopic sebaceous glands

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Diverticula
Pulsion diverticula (pharyngoesophageal, Zenker)
Traction diverticula (midthoracic)
Epiphrenic (pulsion) diverticula
Complications inflammation diverticulitis
perforation
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Achalasia (cardiospasm, megaesophagus)

• Failure of the cardiac mechanism to open
• Loss of myenteric ganglion cells
• Degenerative changes in the remaining ganglion
  cells
• Secondary changes inflammation, fibrosis,
  muscular hypertrophy
• Pathogenesis Unknown. Inflammatory
  immune-mediated disease? Antigen?

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Esophagrams of a patient with early achalasia
pre- and posttreatment.
a Initial esophagram of patient with early
achalasia and no esophageal dilation. b Patient
after 2 years of nonoperative treatment. Note
significant esophageal dilation and air-fluid
level compared to pretreatment. c End-stage
achalasia with sigmoid or megaesophagus.
GI Motility online (May 2006) doi10.1038/gimo53
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Reflux esophagitis gastroesophageal reflux
disease, GERD

• Causes vagal nerve dysfunction, scleroderma,
  Zollinger-Ellison syndrome
• Symptoms regurgitation, heartburn, pain,
  dysphagia
• Microscopically
• epithelial hyperplasia, neutrophils, eosinophils,
  focal epithelial necrosis, dilated and congested
  venules

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GERD
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Barretts esophagus

• Incidence 1,6 of the general population in 10
  of GERD
• Definition replacement of the normal squamous
  epithelium of the lower esophagus by metaplastic
  columnar epithelium
• Diagnosis should be confirmed by histology
• Diagnostic histological features
• Intestinal metaplasia (IM)
• Presence of cardiac and fundic type glands
• Mucin histochemistry
• Presence of neutral and acidic mucins PAS alcian
  blue reaction
• Immunohistochemistry
• CK7 and CK20 positivity MUC2 expression

No goblets, no Barretts
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Squamous mucosa
A
B
Cardiac and oxyntic mucosa
Fundic mucosa
C
D
Fundic mucosa with gastritis (H. pylori)
Intestinal metaplasia
A normal GE junction
B long-segment Barretts esophagus
C carditis with intestinal metaplasia of
cardiac mucosa
D ultra-short segment Barrets esophagus
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Flejou J-F, Svrcek M. Barretts oesophagus - a
pathologists view. Histopathology 2007 503-14.
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Barretts esophagusComplications

• Peptic ulcer
• Stricture
• Bleeding
• Dysplasia
• Adenocarcinoma

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Barrett esophagus and dysplasia
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Adenocarcinoma arising in Barretts esophagus

• Barretts associated adenocarcinoma
  5-10 of all esophageal cancer
• Association with a dysplastic or non-dysplastic
  Barretts mucosa
• Mostly white male, median age at diagnosis 57
  years
• Prognosis poor, 5-yrs survival rate 14.5

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Other types of esophagitis

• Herpes simplex immunosuppressed host
• Cytomegalovirus - immunosuppressed host
• Candida - immunosuppressed host
• AIDS-related chronic idiopathic esophageal
  ulceration
• Crohns disease - rare
• Idiopathic eosinophilic esophagitis - rare

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Squamous cell carcinoma

• Mostly men, over 50 years
• Risk factors smoking, alcohol
• lye strictures, achalasia, Plummer-Vinson
  syndrome, diverticula, irradiation
• Main symptom dysphagia

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Squamous cell carcinomaMorphological features

• Most common in the middle and lower thirds
• Grossly Circumferential, often ulcerated
  Microscopically
• Well or moderately differentiated
• Blood vessel invasion ¾ of the cases!!
• Mestastasis
• Frequent lymph node metastases
• Distant metastases liver, lung, adrenal gland
• Prognosis poor

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Other types of carcinoma

• Sarcomatoid carcinoma
• Verrucosus carcinoma
• Adenocarcinoma (Barretts)
• Adenosquamous carcinoma
• Basaloid (squamous) carcinoma
• Small cell (NE) carcinoma
• Lymphoepithelioma-like carcinoma

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Stomach
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Normal anatomy
cardiac spinchter
fundus
Parietal cells
esophagus
Chief cells
body (corpus)
duodenum
antrum
pylorus
pyloric spinchter
Mucous glands
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The Sidney system for reporting gastritis

• For antral and corpus biopsies to be assessed
  separately
• For gastritis to be classified into
• Acute
• Chronic
• Special (e.g., lymphocytic, granulomatous)
• For the following variables to be graded
• Helicobacter pylori
• Chronic inflammation
• Neutrophils (as a sign of activity)
• Atrophy
• Intestinal metaplasia
• A concluding summary is to be provided (etiology,
  topography, morphology)

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Acute gastritis

• Morphology hyperemia, focal fresh hemorrhage,
  focal necrosis of surface and foveolar cells,
  neutrophilic infiltration
• Causes alcohol, anti-inflammatory drugs
  (salicylates), bile reflux

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Chronic gastritis

• Chronic superficial gastritis
• Chronic atrophic gastritis
• mild, moderate, severe
• gastric atrophy
• Types of chronic gastritis
• type A or immune
• in fundus, antibodies to parietal cells
• type B or nonimmune
• antrum, fundus/pylorus

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The Nobel Prize in Physiology or Medicine 2005
"for their discovery of the bacterium
Helicobacter pylori and its role in gastritis
and peptic ulcer disease"
The idea that this bacterium could cause stomach
ulcers was met with a great deal of scepticism.
Eventually, Barry Marshall deliberately swallowed
a culture of the bacterium. A week later, he
began to suffer acute symptoms of gastritis, and
stomach biopsies revealed that he had become
infected with H. pylori and showed severe acute
gastritis.
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Chronic gastritis - metaplasia

• Pyloric metaplasia
• replacement of the fundic-type glands by mucus
  secreting glands the process moves gradually
  proximally toward cardia
• Intestinal metaplasia
• replacement of the gastric mucosa by intestinal
  epithelium
• complete (type I)
• incomplete (type II)
• Distinguished by whether goblet cells secrete
  sialomucin (complete) versus sulfated
  mucin(incomplete)

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Other types of gastritis

• Acute infectious nonbacterial gastroenteritis
• Hemorrhagic gastritis
• Collagenous gastritis
• Lymphocytic gastritis
• Allergic gastroenteritis
• Granulomatous gastritis
• Syphilis
• Malakoplakia
• CMV infection
• Cryptococcosis
• Bacillary angiomatosis
• Graft-versus-host disease

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Peptic and other benign ulcers

• Places where mucosa is bathed by gastric
  secretion
• stomach, duodenum, lower part of esophagus,
  Meckels diverticulum, margin of
  gastrojejunostomy
• Helicobacter pylori 10-fold higher risk

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Acute gastric ulcer

• Stress ulcer surgery, trauma
• Cushings ulcer CNS injury or disease
• Steroid ulcer
• Curling ulcer excessive burns
• (Erosion ulcer involves only mucosa)
• Complications perforation, hemorrhage

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Chronic peptic ulcer

• In areas lined by pyloric-type mucosa
• (in the body is preceeded by metaplasia)
• 95 on lesser curvature (Magenstrasse)
• 5 multiple
• Dx exulcerated gastric cancer
• Complications hemorrhage, perforation,
  penetration, ? malignant transformation

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Other non-neoplastic lesions

• Duplication
• Diverticula
• Cysts
• Bezoars
• Aneurysms of gastric vessels
• Gastric antral vascular ectasia
• Xanthoma
• Hypertrophic pyloric stenosis

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Polyps
A mass of tissue that develops on the inside wall
of a hollow organ, as within the colon or rectum.
The word polyp comes from the Greek words polys,
many pous, feet. The idea that a polyp has many
feet is erroneous. Most polyps have a single
pedicle. The term polyp is descriptive. Polyps
may be benign, premalignant, or malignant.
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Gastric polyps

• Hyperplastic (inflammatory) polyp
• Adenomas
• true neoplastic lesions, composed of dysplastic
  glands
• Mixed (hyperplastic and adenomatous)
• Fundic gland polyp
• Inflammatory fibroid polyp
• Hamartomatous polyp

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Gastric carcinoma

• Intestinal type
• role of environmental factors
• chronic atrophic gastritis with intestinal
  metaplasia
• H. pylori (through chr. gastritis)
• Diffuse type
• less related to environmental factors, not rarely
  in young individuals, linitis plastica,
  Krukenberg tumor
• Lymphoepithelioma-like (7-10)
• Epstein-Barr virus

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Early gastric cancer

• Early gastric cancer (EGC) is a carcinoma limited
  to the mucosa or the mucosa and submucosa,
  regardless of nodal status.

Type I Protruded Type IIa Elevated Type
IIb Flat Type IIc Depressed Type III Excavated
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Clinicopathologic approach to Napoleons gastric
illness on St Helena (18151821)
Lugli A et al. (2007) Napoleon Bonapartes
gastric cancer a clinicopathologic approach to
staging, pathogenesis, and etiology Nat Clin
Pract Gastroenterol Hepatol 4 5257
doi10.1038/ncpgasthep0684
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Well differentiated neuroendocrine tumors
(carcinoid)
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Stromal tumors of the GI tract

• Majority of non-epithelial neoplasms in GI tract
• Adulthood (15-80 yrs) MFequal
• Localisation
• Symptoms abdominal discomfort, bleeding
• Prognosis variable

stomach 50 -60 small intestine 20 -30 colon
10 esophagus 5 extra GI tract
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GI pacemaker or Cajal cells
Santiago Ramón y Cajal 1852-1934 Nobel prize 1906
CD117
Cajal SR. Sur les ganglions et plexus nerveux
d'intestin. C R Soc Biol (Paris) 1893 5 217-223
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Epithelioid cell GIST
Spindle cell GIST
High-risk GIST
GIST hepatic metastasis
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