Pathology of

gastrointestinal

tract I

MUDr. Helena Skálová

- Esophagus - Stomach

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

• 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

Motoric dysfunction of esophagus

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

• Fibroma, lipoma, hemangioma …

• Squamocellular papiloma

• Squamocellular carcinoma

• 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

Malignant

Adenoma Leiomyoma

• Carcinoma (93%)

• Lymphoma (4%)

• GIST (2%)

• NET = carcinoid (3%)

Polyps

• Hyperplastic polyp • Fundic gland polyp

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