Post on 17-Oct-2018
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