PATHOLOGY OF THE PATHOLOGY OF THE ESOPHAGUSESOPHAGUS

Symptoms of the esophageal disordersSymptoms of the esophageal disorders

Upper gastrointestinal Upper gastrointestinal bleedingbleeding (lacerations, (lacerations, varices)varices)

OdynophagiaOdynophagia (painful swallowing)--infections, (painful swallowing)--infections, other inflammatory insults other inflammatory insults

DysphagiaDysphagia (difficulty swallowing)-disorders of (difficulty swallowing)-disorders of motility (solids and liquids), obstructions such as motility (solids and liquids), obstructions such as tumors and benign strictures (solids first, tumors and benign strictures (solids first, progressing to liquids). progressing to liquids).

DisordersDisorders

HHiatal herniaiatal hernia

AAchalasiachalasia

LacerationsLacerations (Mallory-Weiss Syndrome(Mallory-Weiss Syndrome))

VVaricesarices

Stenosis, webs and ringsStenosis, webs and rings

EsophagitisEsophagitis

Esophageal carcinomaEsophageal carcinoma

ANATOMIC & MOTOR DISORDERSANATOMIC & MOTOR DISORDERS

Hiatal herniaHiatal hernia

1-20% of population; 9% symptomatic1-20% of population; 9% symptomatic

Characterized by Characterized by separation of the diaphragmatic crura and separation of the diaphragmatic crura and – widening of the space between the muscular widening of the space between the muscular

crura and the esophageal wallcrura and the esophageal wall..

Complications:Complications: U Ulceratlcerationion, bleeding, bleeding, , perforationperforation, r, reflux esophagitiseflux esophagitis..

Types of Hiatal herniaTypes of Hiatal hernia

Type 1Type 1 (Sliding)-- (Sliding)--95%; protrusion of the 95%; protrusion of the stomach above the diaphragm creates a stomach above the diaphragm creates a bell shaped dilation bell shaped dilation

Type 2Type 2 (Paraesophageal)-- (Paraesophageal)--stomach rolls stomach rolls along side of lower esophageal sphincter along side of lower esophageal sphincter (LES), may strangulate or obstruct and (LES), may strangulate or obstruct and thus is often managed surgically. thus is often managed surgically.

ACHALASIAACHALASIAFFailure of relaxation with consequent dilatation ailure of relaxation with consequent dilatation of the esophagusof the esophagus

CClinicallylinically progressive dysphagia and progressive dysphagia and regurgitationregurgitation

MManifest in young adulthood but may appear in anifest in young adulthood but may appear in infancy or childhoodinfancy or childhood

Manometric studies show three major Manometric studies show three major abnormalities of the achalasia: abnormalities of the achalasia: – (1) aperistalsis, (1) aperistalsis, – (2) partial or incomplete relaxation of the (2) partial or incomplete relaxation of the lower esophageal lower esophageal

sphincter (sphincter (LESLES)) with swallowing, with swallowing, – (3) increased resting tone of the LES(3) increased resting tone of the LES..

Primary achalasia:Primary achalasia: primary degenerative primary degenerative changes in neural innervationchanges in neural innervationSecondary achalasia:Secondary achalasia:– Chagas’ diseaseChagas’ disease ((Trypanosoma cruziTrypanosoma cruzi)) causes causes

destruction of the myenteric plexus of the destruction of the myenteric plexus of the esophagus, duodenum, colon, and ureter, with esophagus, duodenum, colon, and ureter, with resultant dilatation of these structuresresultant dilatation of these structures

– Diseases of the vagal dorsal motor nuclei, Diseases of the vagal dorsal motor nuclei, particularly polio or surgical ablation, particularly polio or surgical ablation,

– DDiabetic autonomic neuropathyiabetic autonomic neuropathy,,– IInfiltrative disordersnfiltrative disorders ( (malignancy, amyloidosis,malignancy, amyloidosis,

sarcoidosissarcoidosis), ), – Infectious diseases (pneumonia, Infectious diseases (pneumonia, candida candida

albicansalbicans esophagitis) esophagitis). .

Achalasia Achalasia

LacerationsLacerations (Mallory-Weiss Syndrome) (Mallory-Weiss Syndrome)

Longitudinal tears in the esophagus at the Longitudinal tears in the esophagus at the esophagogastric junction esophagogastric junction

common in alcoholicscommon in alcoholics

5 to 10% of upper gastrointestinal bleeding 5 to 10% of upper gastrointestinal bleeding episodesepisodes. .

VaricesVaricesPPortal hypertensionortal hypertension collateral bypass collateral bypass channels channels ((wherever the portal and caval wherever the portal and caval systems communicatesystems communicate))The increased pressure in the esophageal The increased pressure in the esophageal plexus produces dilated tortuous vessels plexus produces dilated tortuous vessels called varices. called varices. TTwo-thirds of all cirrhotic patients and are wo-thirds of all cirrhotic patients and are most often associated with alcoholic most often associated with alcoholic cirrhosis.cirrhosis.NNo symptoms until they ruptureo symptoms until they rupture.. MMassive hematemesis assive hematemesis

Stenosis, Webs, and RingsStenosis, Webs, and Rings

Non-neoplastic constrictions Non-neoplastic constrictions (stenoses)(stenoses)::

Primary:Primary: developmental defects developmental defects

SecondarySecondary ( (severe esophageal injurysevere esophageal injury):):– gastroesophageal reflux, gastroesophageal reflux, – radiation, radiation, – scleroderma, scleroderma, – caustic injury.caustic injury.

Progressive dysphagiaProgressive dysphagia

Perforation of the esophagusPerforation of the esophagus

Boerhaave syndromeBoerhaave syndrome

Most commonly due to trauma (nasogastric Most commonly due to trauma (nasogastric tube)tube)

or excessive vomitingor excessive vomitingGross:Gross: may be indistinct, or associated with a may be indistinct, or associated with a

small amount of hemorrhagesmall amount of hemorrhage

Complications:Complications: bacterial mediastinitis, which bacterial mediastinitis, which has a high mortality, even with the use of has a high mortality, even with the use of broad-spectrum antibioticsbroad-spectrum antibiotics..

Plummer-Vinson syndromePlummer-Vinson syndrome

((Paterson-KellyPaterson-Kelly syndrome): syndrome):– 1. microcytic hypochromic 1. microcytic hypochromic anemia,anemia, – 2. esophageal webs (p2. esophageal webs (progressive dysphagiarogressive dysphagia),),– 3. atrophic glossitis.3. atrophic glossitis.

INFLAMMATORY DISORDERSINFLAMMATORY DISORDERS

ESOPHAGITISESOPHAGITISTypesTypes

- Corrosive Corrosive - Infectious--CMV/Herpes/Candida Infectious--CMV/Herpes/Candida - Reflux.Reflux.

Injury to the esophageal mucosa with Injury to the esophageal mucosa with subsequent inflammation is common worldwide. subsequent inflammation is common worldwide.

In northern Iran, the prevalence of esophagitis is In northern Iran, the prevalence of esophagitis is more than 80%more than 80% (hot tea). (hot tea).

IIt is also extremely high in regions of China. t is also extremely high in regions of China.

Disease and OriginDisease and Origin– Reflux esophagitisReflux esophagitis, via reflux of gastric contents., via reflux of gastric contents.– Prolonged gastric intubationProlonged gastric intubation..– Ingestion of irritantsIngestion of irritants, such as alcohol, corrosive , such as alcohol, corrosive

acids or alkalis (in suicide attempts), excessively acids or alkalis (in suicide attempts), excessively hot fluids (i.e., hot tea in Iran), and heavy hot fluids (i.e., hot tea in Iran), and heavy smoking.smoking.

– Cytotoxic anticancer therapyCytotoxic anticancer therapy, with or without , with or without superimposed infection.superimposed infection.

– InfectionInfection following bacteremia or viremiafollowing bacteremia or viremia ( (herpes herpes simplex viruses and cytomegalovirus are the simplex viruses and cytomegalovirus are the more common offenders in the more common offenders in the immunosuppressedimmunosuppressed))..

– Fungal infectionFungal infection in debilitated or in debilitated or immunosuppressed patients or during broad-immunosuppressed patients or during broad-spectrum antimicrobial therapy. Candidiasis is the spectrum antimicrobial therapy. Candidiasis is the most common; mucormycosis and aspergillosis most common; mucormycosis and aspergillosis may occur.may occur.

– UremiaUremia..– RadiationRadiation..– Systemic conditionsSystemic conditions associated with decreased LES associated with decreased LES

tone, including hypothyroidism, systemic sclerosis, tone, including hypothyroidism, systemic sclerosis, and pregnancy.and pregnancy.

– In association with In association with systemic desquamative systemic desquamative dermatologic conditionsdermatologic conditions,, such as pemphigoid and such as pemphigoid and epidermolysis bullosa.epidermolysis bullosa.

– Graft-versus-host diseaseGraft-versus-host disease..

MorphologyMorphology

The anatomic changes depend on the The anatomic changes depend on the causative agentcausative agent and on the and on the duration duration andand severity of the exposureseverity of the exposure::

Simple hyperemia Simple hyperemia

IIn n reflux esophagitis, three features are reflux esophagitis, three features are characteristiccharacteristic:: eosinophils, with or without neutrophilseosinophils, with or without neutrophils, , in the in the epithelial layerepithelial layer

basal zone hyperplasiabasal zone hyperplasia

elongation of lamina propria papillaeelongation of lamina propria papillae . .

TThe final common pathway for all is he final common pathway for all is – severe acute inflammation, severe acute inflammation, – superficial necrosissuperficial necrosis (erosion), (erosion),– ulceration with the formation of granulation tissue, ulceration with the formation of granulation tissue, – accumulation of adherent purulent debris, accumulation of adherent purulent debris, – and eventual fibrosis.and eventual fibrosis.

In infectious dieseases:In infectious dieseases:– CandidiasisCandidiasis: : gray-white pseudomembranesgray-white pseudomembranes– Herpes and cytomegalovirusHerpes and cytomegalovirus: : punched-out ulcerspunched-out ulcers, ,

inclusionsinclusions– Pathogenic bacteriaPathogenic bacteria: : bacterial invasion with bacterial invasion with

ulcerations.ulcerations.

IIrradiationrradiation:: – intimal proliferation with luminal narrowingintimal proliferation with luminal narrowing in blood in blood

vessels, vessels, – fibrosis and mucosal atrophyfibrosis and mucosal atrophy..

Chemically induced injury ( acids, detergents)Chemically induced injury ( acids, detergents):: – severe necrosis of the esophageal wall, severe necrosis of the esophageal wall, – hemorrhage hemorrhage – severe inflammation. severe inflammation.

Graft-versus-host diseaseGraft-versus-host disease::– karyorrhexis of basal epithelial cells, karyorrhexis of basal epithelial cells, – atrophy, atrophy, – ffibrosis of the lamina propria with minimal ibrosis of the lamina propria with minimal

inflammation.inflammation.

Candida albicansCandida albicans

SSuperficial, curdy, gray to white inflammatory uperficial, curdy, gray to white inflammatory membrane composed of matted organisms membrane composed of matted organisms

fibrinosuppurative exudate fibrinosuppurative exudate withwith an underlying an underlying erythematous inflammatory baseerythematous inflammatory base

Risk factors: Risk factors: – DiabetDiabetes mellituses mellitus, , – neutropenineutropeniaa,,– immunoincompetent, immunoincompetent, – AIDS, AIDS, – XXerostomia, erostomia, aantibiotic therapy.ntibiotic therapy.

Barrett’s EsophagusBarrett’s Esophagus

A A premalignant condition in which the normal stratified premalignant condition in which the normal stratified squamous epithelium of the esophagus is replaced by squamous epithelium of the esophagus is replaced by a a metaplasticmetaplastic columnar epithelium as a complication columnar epithelium as a complication of chronic gastroesophageal reflux disease (GERD).of chronic gastroesophageal reflux disease (GERD).

The metaplastic epithelium of Barrett's esophagus is The metaplastic epithelium of Barrett's esophagus is variously called variously called – Barrett's metaplasia, Barrett's metaplasia, – specialized columnar metaplasia specialized columnar metaplasia – intestinal metaplasia.intestinal metaplasia.

RRed, velvety mucosa located between the ed, velvety mucosa located between the smooth, pale pink esophageal squamous smooth, pale pink esophageal squamous mucosa and the more lush, light brown mucosa and the more lush, light brown gastric mucosagastric mucosa..

MicroscopicallyMicroscopically:: – the esophageal squamous epithelium is the esophageal squamous epithelium is

replaced by replaced by metaplastic columnar epitheliummetaplastic columnar epithelium..– ddysplasiaysplasia ( (the presumed precursor of the presumed precursor of

malignancymalignancy))

Only about Only about 5-10%5-10% of patients with Barrett's of patients with Barrett's esophagus will progress to cancer. esophagus will progress to cancer.

EndoscopyEndoscopy with biopsy is therefore with biopsy is therefore recommended in patients who have long-recommended in patients who have long-standing or frequent standing or frequent gastroesophageal gastroesophageal reflux disease reflux disease (GERD) symptoms to (GERD) symptoms to determine whether or not Barrett's determine whether or not Barrett's esophagus has developed. esophagus has developed.

Barret’sBarret’s

Barrett's esophagus

No malignancy Adenocarcinoma

TUMORS of the ESOPHAGUSTUMORS of the ESOPHAGUS

Benign tumorsBenign tumors

– RareRare

Malignant tumorsMalignant tumors

– Squamous cell Squamous cell carcinoma (90%)carcinoma (90%)

– Adenocarcinoma Adenocarcinoma (associated with (associated with Barret’s esophagus)Barret’s esophagus)

SQUAMOUS CELL CARCINOMASQUAMOUS CELL CARCINOMA

Risk factorsRisk factorsEsophageal disordersEsophageal disorders– Long standing esophagitisLong standing esophagitis– AchalasiaAchalasia– Plummer-Vinson syndromePlummer-Vinson syndrome

Life styleLife style– AlcoholAlcohol– TobaccoTobacco

VirusVirus– Human papillomavirusHuman papillomavirus

DietaryDietary– Hypovitaminosis (A,B,C)Hypovitaminosis (A,B,C)– Deficiency of trace elements (zinc, Deficiency of trace elements (zinc,

molybdenum)molybdenum)– Fungal contamination of foodstuffFungal contamination of foodstuff– High contents of nitrits / nitrosaminesHigh contents of nitrits / nitrosamines

Genetic dispositionGenetic disposition– Tylosis (hyperkeratosis of palms and soles)Tylosis (hyperkeratosis of palms and soles)

Squamous cell carcinomaSquamous cell carcinoma

– Usually preceed by epithelial dysplasia and Usually preceed by epithelial dysplasia and carcinoma in situ,carcinoma in situ,

– Early lesions: small, gray-white mucosal Early lesions: small, gray-white mucosal thickenings,thickenings,

– Three forms:Three forms:1. Polypoid exophytic1. Polypoid exophytic2. Necrotizing-ulcerative2. Necrotizing-ulcerative3. Diffuse infiltrative3. Diffuse infiltrative

Localization:Localization:– Upper upper third (20%)Upper upper third (20%)– Middle third (50%)Middle third (50%)– Lower third (% 30).Lower third (% 30).

Adenocarcinomas of the Adenocarcinomas of the esophagusesophagus

– Barret’s esophagusBarret’s esophagus– Lower thirdLower third– Invasion of cardiaInvasion of cardia– Forms:Forms:

NodularNodular

DiffuseDiffuse

Infiltrative.Infiltrative.

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