Oesophagus congenital anomalies, motor dysfunction, gerd and tumours 28-5-2016

Pathology of Esophagus

T.Mathumithra

© 2008 Chettinad Hospital & Research Institute

OESOPHAGUS

• Motor dysfunction –acalasia cardia• Gastro-oesophageal reflux disease (GERD)• Barrett’s oesophagus• Tumours


About THE OESOPHAGUS……..

There are 2 sphincters • UES: 3 cm segment at the

level of crico-pharyngeus muscle

• LES: 2 – 4 cm segment just proximal to GE junction25 cm


ANATOMY OF THE OESOPHAGUS• It is lined throughout by

stratified squamous epithelium

• Most of oesophagus lacks serosa (infection and tumours spread early)


PRINCIPAL SYMPTOMS OF OESOPHAGEAL DISORDERS• Heartburn (retro-sternal burning pain) primary symptom of gastro-esophageal reflux burning sensation that radiates up from the

stomach to the chest & throat. • Dysphagia • Odynophagia• Haematemesis


SPECIAL DIAGNOSTIC PROCEDURES IN OESOPHAGEAL DISORDERS• Oesophagoscopy• Radiographic barium

studies


OESOPHAGUS - MOTOR DISORDERS (ACHALASIA)

(1) aperistalsis, (2) incomplete relaxationof LES with swallowing &(3) ed resting tone of LES

Idiopathic - thought to be due to loss ofneurons containing NO & VIPChagas disease (Trypansoma cruzi) destruction of the myenteric plexus in the walls of esophagus


In patients with portal hypertension (usually micronodular cirrhosis from chronic alcoholism or schistosomiasis ), the sub-mucosal esophageal veins become dilated (form varices). These varices are prone to bleed & cause death in ~ 40% of patients with advanced cirrhosis.

Oesophageal Varices

OESOPHAGITIS• Most common cause is gastro-esophageal reflux

disease (GERD or reflux oesophagitis)• Other causes:

• Ingestion of mucosal irritants; smoking etc.,• In immune deficient patients:

• Viral – CMV; Herpes simplex• Fungal – Candidiasis (thrush);

mucormycosis; aspergillosis.• Uraemic


CAUSES OF GASTRO-OESOPHAGEAL REFLUX

1) Mechanically incompetent lower LESsed sphincter pressure

2) Inefficient clearance of refluxed gastric juice


OESOPHAGITIS – GERD - PATHOGENESIS

• Decreased efficacy of anti-reflux mechanisms – CNS depressants – alcohol \ tobacco exposure


OESOPHAGITIS – GERD

• adults over 40yrs

• Clinically – heart burn, dysphagia, regurgitation

• May develop stricture or Barrett oesophagus


REFLUX OESOPHAGITIS• Presence of

inflammatory cells (eosinophils & neutrophils) in the squamous epithelium;

• Elongation of lamina propria;

• Basal zone hyperplasia

Normal oesophageal mucosa

Reflux oesophagitis

OESOPHAGITIS - BARRETT OESOPHAGUS

• Chronic GERD --glandular metaplasia of the lower oesophagus-- known as Barrett oesophagus

• 10% of GERD patients

• Consist of transformation of squamous epithelium into columnar epithelium with many goblet cell

• Adenoca risk (30-40 fold increase)


20

BARRETT OESOPHAGUS• Two types:

• Long segment (>3cm)• Short segment (<3cm)

• Criteria for diagnosis• Endoscopic evidence of

columnar epithelial lining above GE junction

• Histologic evidence of intestinal metaplasia

Normal Oesophagus

Barrett Oesophagus

Dept of pathology, CHRI. 21

NEOPLASMS OF THE OESOPHAGUS

• Benign – mostly mesenchymal• Leiomyoma, fibroma, lipoma, neurofibroma,

lymphangioma etc

• Squamous papillomas – rare; When it is positive for HPV, it is called condyloma

• Malignant (6% of all malignancies of GIT)• Squamous cell carcinoma • Adenocarcinoma


ADENOCARCINOMA OF THE OESOPHAGUS

• After 40 years of age; median age – 6th decade

• more often in men

• 10% of patients with Barrett oesophagus will develop adenocarcinomas arising from the Barrett epithelium

• Other risk factors: tobacco smoking; obesity


ADENOCARCINOMA ARISING FROM BARRETT’S OESOPHAGUS• Usually located in distal

oesophagus

• Flat, raised or nodular lesions

• Infiltrating Malignant glands

• 5-year survival rate- <

20%


SQUAMOUS CELL CARCINOMA - OESOPHAGUS• Most common primary malignant tumor of the esophagus

• accounts for 4% of all fatal cancers

• M:F = 4:1 (2 – 20:1)

• Most common in middle 1/3 of oesophagus

• Spreads early

• Rat tail appearance on barium swallow

• Poor prognosis


FACTORS ASSOCIATED WITH SQUAMOUS CELL CARCINOMA OF OESOPHAGUSDietary • lack of vitamins (A,

B1) Nitrites/nitrosamines

Lifestyle• Alcohol consumption • Tobacco use• Urban environment

Oesophageal disorders• Long-standing

esophagitis• Achalasia• Plummer-Vinson

SyndromeGenetic


SQUAMOUS CELL CARCINOMA - OESOPHAGUS• Clinical features

• Progressive dysphagia, usually not recognized until the lumen is 30-50% occluded

• Steady sub-sternal or back pain; hoarseness and cough

• Weight loss and anorexia; blood loss


SQUAMOUS CELL CARCINOMA OESOPHAGUS

• 50% of carcinomas show p53 mutations• Location of tumours: 20% in upper third, 50% in

middle third & 30% in the lower third. • Gross patterns: polypoid (60%), flat (15%) ulcerated (25%)


SQUAMOUS CELL CARCINOMA - OESOPHAGUS


Thank you!


Oesophagus congenital anomalies, motor dysfunction, gerd and tumours 28-5-2016

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Transcript of Oesophagus congenital anomalies, motor dysfunction, gerd and tumours 28-5-2016