Upper GIT II

Luigi TornilloPathoBasic 09.09.2014

Pathology

• Esofagus : inflammation II– Infectious esophagitis– Drug esophagits– Radiation esophagitis

• Stomach : inflammation II– Drug gastritis– Granulomatous gastritis– Lymphocytic gastritis

Esophagus: inflammation

• GERD• Eosinophilic esophagitis• Infective

– Candida– CMV, HSV– Immunocompetent: measles, scarlet,

dyphteria– Immunodeficient: HIV, HZV, HPV, HHV6, varied

bacteria & fungi• Drugs, Toxic• Radiation esophagitis• GvHD

Herpes Infection

• Immunocompromised– HIV, transplant.

Immunosupp. therapy, tumors

• Immuncompetent (?)– Children, elderly,

pregnancy• Dysphagia, odinophagia• Middle, lower esophagus• Punched -out ulcers,

multiple vesicles

Herpes Infection

• Ulcer edge• Mixed inflammatory infiltrate (also

macrophages )• Multinucleated epithelial cells with viral

inclusions (IHC)• „Dirty “ background

Candida Infection

• Immunocompromised– HIV, transplant.

Immunosupp. therapy, tumors

• Immuncompetent (?)– Children, elderly,

• Dysphagia , odinophagia• Whitish , bleeding

membranes

Riddell, 2nd ed

Drug (pill) esophagitis

• Elderly pat., M/F 1/2• Swallowing pills dry

– KCL, NSAIDs, ASA, Tetracyclines, iron, biphosphonates, quinidine

• Focal, mid esophagus• Histology not specific ,

(Acute ) GvHD

• Rare, upperesophagus

• Apoptoticepithelial cells

• Scantymononuclearinfiltrate

Radiation esophagitis

• If chemoradio more frequent

• Smaller epithelial cells

• Nuclear alterations

• Submucosal changes

• Bizarre endothelia

Stomach : inflammation II

Lymphocytic gastritis

• IEL (> 25/100), surface and foveolae

• 1% of gastroscopies• Sometimes focal• Varioliform , large

mucosal folds

• Infections ( HP, HIV)• Immune-mediated

– Celiac disease,Crohn, CVID

• Tumors• Drugs (of course...)

– Ticlodipine

CD3 CD8

Granulomatous gastritis

• Crohn (<5%, not specific)– NB: FAG

• Infection– HP, TBC, Syphilis, Histoplasmosis

• Vasculitis , Amyloid , Rheumatoid, Sarcoid , Foreign material

• Malignancy

Stomach: Granulomas

• Neutrophils = recent• Eosinophils = parasite• Compact with no gastritis = sarcoidosis• Compact with gastritis = Crohn• Necrosis = infection • Ulcer = foreign body (?)

Iatrogenic gastropathies

Erosions/ulcersNSAID, KCl, alendronate, colchicine, biphosph., Fe, steroids

Hemorragic gastritisNSAID, KCl, antibiotics, biphosph., Fe, steroids, kayexalate, taxol

Reactive (chemical) gastropathy

NSAID

Pariet. Cell Hyp., FGP PPI

Ep. Atypia („dysplastic“) Chemotherapy (5FU, mytomicine )

Lymphocytic gastritis Ticlodipine

Pathologie

Epithelial apoptosis

• PPI• Colchicine• Conditioning/chemo• Mycophenolate• Cave: GVHD• Antrum• Glands neck

Non-specific pill inflammation(esophagus and stomach )

• KCL, alendronate, doxycycline, quinidine, iron, kayexalate, taxol, NSAID

• Neutrophilic inflammation

• Ulcer, strictures

Pathologie

Pathologie

Drug: lymphocytic gastritis

Drug / Chemical Gastropathy

• NSAID• Proliferative

compartment• Regeneration• Large nuclei

(„atypical“)

Pathologie

„Dysplastic“ changes (colchicine)

Pathologie

Gastric GvHD

• Scantyinflammation , mostlymononuclear

• Apoptosis– Corpus (neck,

surface)– Rare in antrum

(deep!)

Autoimmune gastritis

„Immune -mediated progressive destruction of parietal cells leading to reduced acid production and reducedor absent intrinsic factor (IF)“

Riddell, 2nd Ed., 2014

Autoimmune gastritis

• Antiparietal cell antibodies, achlorhydria , prevalent body

• HP involved (cross -reaction?)

• Other autoimmune diseases

Autoimmune gastritis

• Pebbled appearance to mucosa• Corpus -predominant, mild

activity• Intestinal and/or pancreatic

metaplasia , los s of parietal and chief cells

• ECL in corpus, G cell in antrum

2 clusters 5 cells/mm or HPF

< 0,5mm5 or more micronodularhyperplasia

Gastric atrophy

“Absence of glands that should normally be present in the gastric area in question, irrespective of what replaces them ”

• Nothing (“empty lamina propria ”)• Fibrosis• Other glands not native to the area

Gastric atrophy : meaning

• Antrum– No meaning

• Corpus, mild to moderate– Hypochlorhydria

• Corpus, severe– Severe hypochlorhydria, achlorhydria– Vit. B 12 malabsorption

Gastric atrophy : report

• Reporting gastric atrophy only if it issevere and in corpus

• Essential separate biopsies of corpus

• Severe extensive metaplasia : surveillance

• Shepherd et al. (eds.), Morson & Dawson‘sGastrointestinal Pathology, 5th ed., Hoboken , NY, 2013

• Riddell & Jain (eds.), Riddell‘s GastrointestinalPathology and its Clinical Implications, 2nd ed., Philadelphia, PA, 2014

• Liacouras et al., J Allergy Clin Immunol, 2011; 128(1):3–20.e6

• Straumann A, Dig Dis Sci, 2013;31:6–9• Almashat SJ et al, Sem Diagn Pathol, 2014; 31:

89-99 • Maguire and Sheehan , Histopathology,

2012;60:864-79• Parfitt & Driman , Human Pathology, 2007; 38:

527– 536