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| '''Esophagus''' connects the pharynx to the [[stomach]]. It is afflicted by tumours on occasion. For some reason or another, it seems everyone at SMH gets a esophageal biopsy... yet patients at SB don't have esophagi. | | [[Image:Tractus intestinalis esophagus.svg|thumb|250px|A schematic of the esophagus.]] |
| | '''Esophagus''' connects the pharynx to the [[stomach]]. It is afflicted by tumours on occasion. Probably the most common affliction is [[gastroesophageal reflux disease]] (GERD). Most biopsies revolve around the questions: 1. intestinal metaplasia? 2. dysplasia? and 3. cancer? |
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| =Normal= | | =Normal esophagus= |
| General: | | General: |
| *Stratified squamous non-keratinized epithelium. | | *Stratified squamous non-keratinized epithelium. |
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| **Mitoses should be rare and should NOT be above the basal layer. | | **Mitoses should be rare and should NOT be above the basal layer. |
| *Inflammatory cells should be very rare. | | *Inflammatory cells should be very rare. |
| | |
| | ==Sign out== |
| | ===Nonspecific inflammation=== |
| | <pre> |
| | Esophagus, Distal, Biopsy: |
| | - Columnar epithelium with moderate chronic inflammation. |
| | - Reactive squamous epithelium. |
| | - NEGATIVE for intestinal metaplasia. |
| | - NEGATIVE for dysplasia and NEGATIVE for malignancy. |
| | </pre> |
| | |
| | ====Block letters==== |
| | <pre> |
| | ESOPHAGUS, DISTAL, BIOPSY: |
| | - COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INFLAMMATION. |
| | - REACTIVE SQUAMOUS EPITHELIUM. |
| | - NEGATIVE FOR INTESTINAL METAPLASIA. |
| | - NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY. |
| | </pre> |
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| =Diagnoses= | | =Diagnoses= |
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| | - | | | - |
| | - | | | - |
| | [http://commons.wikimedia.org/wiki/File:Tinci%C3%B3n_hematoxilina-eosina.jpg] | | | [[Image:Tinci%C3%B3n_hematoxilina-eosina.jpg|center|thumb|125px|Normal esophagus. (WC)]] |
| |- | | |- |
| |GERD | | |GERD |
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| | | | | |
| | incr. risk of Barrett's | | | incr. risk of Barrett's |
| | | | | [[Image:Gastroesophageal reflux disease -- low mag.jpg|center|thumb|125px|c/w GERD. (WC)]] |
| |- | | |- |
| |Eosinophilic esophagitis | | |[[Eosinophilic esophagitis]] |
| | abundant eosinophils | | | abundant eosinophils |
| | elongated (epithelial) papillae, basal cell hyperplasia, lymphocytes | | | elongated (epithelial) papillae, basal cell hyperplasia, lymphocytes |
| | | | | |
| | unresponsive to PPIs | | | unresponsive to PPIs |
| | [http://en.wikipedia.org/wiki/File:Eosinophilic_esophagiits_path.jpg microscopic], [http://en.wikipedia.org/wiki/File:Eosinophilic_esophagiits_path.jpg endoscopic] | | | [[Image:Eosinophilic_esophagitis_-_2_-_very_high_mag.jpg|center|thumb|125px|Eosinophilic esophagitis. (WC/Nephron)]] |
| |- | | |- |
| |Barrett's type change | | |[[Barrett's esophagus|Barrett's type change]] |
| | goblet cells | | | goblet cells |
| | no dysplasia | | | no dysplasia |
| | Alcian blue +ve | | | Alcian blue +ve |
| | incr. risk of adenocarcinoma | | | incr. risk of adenocarcinoma |
| | [http://commons.wikimedia.org/wiki/File:Barretts_alcian_blue.jpg] | | | [[Image:Barretts_alcian_blue.jpg|center|thumb|125px|Barrett's esophagus. Alcian blue. (WC)]] |
| |- | | |- |
| |Dysplasia, low grade | | |[[Columnar dysplasia of the esophagus|Dysplasia, low grade]] |
| | nuclear crowding at surface | | | nuclear crowding at surface |
| | hyperchromasia, mild arch. complexity, no necrosis | | | hyperchromasia, mild arch. complexity, no necrosis |
| | | | | |
| | incr. risk of carcinoma | | | incr. risk of carcinoma |
| | | | | [[Image:Low-grade columnar dysplasia of the esophagus -- intermed mag.jpg|thumb|110px|LGH - intermed. mag.]] |
| |- | | |- |
| |Dysplasia, high grade | | | [[Columnar dysplasia of the esophagus|Dysplasia, high grade]] |
| | cribriforming and/or necrosis | | | [[cribriform]]ing and/or necrosis |
| | nuclei often round & large, hyperchromasia | | | nuclei often round & large, hyperchromasia |
| | | | | |
| | marked incr. risk of carcinoma | | | marked incr. risk of carcinoma |
| | | | | [[Image:High-grade columnar dysplasia of the esophagus -- high mag.jpg|thumb|110px|HGD - high mag.]] |
| <!-- | | <!-- |
| |Entity | | |Entity |
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| | - | | | - |
| | - | | | - |
| | Image | | | [[Image:Tinci%C3%B3n_hematoxilina-eosina.jpg|center|thumb|125px|Normal esophagus. (WC)]] |
| |- | | |- |
| |Barrett's eosphagus | | |Barrett's esophagus |
| | matures | | | matures |
| | round glands, normal gland density | | | round glands, normal gland density |
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| | - | | | - |
| | follow-up | | | follow-up |
| | Image | | | [[Image:Low-grade columnar dysplasia of the esophagus -- intermed mag.jpg|thumb|110px|LGH - intermed. mag.]] |
| |- | | |- |
| |High-grade columnar dysplasia | | |High-grade columnar dysplasia |
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| | moderate-to-marked nuclear atypia (usu. plump round nuclei), hyperchromasia, +/-necrosis | | | moderate-to-marked nuclear atypia (usu. plump round nuclei), hyperchromasia, +/-necrosis |
| | - | | | - |
| | EMR, surgery | | | [[EMR]], surgery |
| | Image | | | [[Image:High-grade columnar dysplasia of the esophagus -- high mag.jpg|thumb|110px|HGD - high mag.]] |
| |- | | |- |
| |Intramucosal adenocarcinoma | | |Intramucosal adenocarcinoma |
| | no maturation | | | no maturation |
| | single cells or '''back-to-back irregular glands''' with budding and/or '''cribriforming''' and/or '''gland dilation''' or glands with long axis along muscularis mucosae | | | single cells or '''back-to-back irregular glands''' with budding and/or '''[[cribriform]]ing''' and/or '''gland dilation''' or glands with long axis along muscularis mucosae |
| | moderate-to-marked nuclear atypia - usu. round large nuclei, hyperchromasia, +/-necrosis | | | moderate-to-marked nuclear atypia - usu. round large nuclei, hyperchromasia, +/-necrosis |
| | - | | | - |
| | EMR, surgery | | | [[EMR]], surgery |
| | Image | | | [[Image:Esophageal_adenocarcinoma_-_high_mag.jpg|thumb|110px|Adenocarcinoma - high mag.]] |
| |} | | |} |
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| | low vs. high | | | low vs. high |
| |- | | |- |
| | Desmoplasia | | | [[Desmoplasia]] |
| | absent | | | absent |
| | absent | | | absent |
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| |- | | |- |
| |} | | |} |
| | |
| | ====Decision tree for columnar dysplasia==== |
| | Odze has made an algorithm - see: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861756/figure/fig8/ Diagnostic algorithm (nih.gov)].<ref name=pmid17021130>{{Cite journal | last1 = Odze | first1 = RD. | title = Diagnosis and grading of dysplasia in Barrett's oesophagus. | journal = J Clin Pathol | volume = 59 | issue = 10 | pages = 1029-38 | month = Oct | year = 2006 | doi = 10.1136/jcp.2005.035337 | PMID = 17021130 }}</ref> |
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| ==Indications== | | ==Indications== |
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| {{Main|Candidiasis}} | | {{Main|Candidiasis}} |
| *[[AKA]] ''esophageal candidiasis''. | | *[[AKA]] ''esophageal candidiasis''. |
| | |
| ====Gross (endoscopic)==== | | ====Gross (endoscopic)==== |
| Features: | | Features: |
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| ====Microscopic==== | | ====Microscopic==== |
| Features: | | Features: |
| *Worm-like micro-organisms. | | *Worm-like micro-organisms - '''key feature'''. |
| **Pseudohyphae (single cells). | | **Pseudohyphae (single cells). |
| **Thickness ~ 1/3-1/2 of squamous cell nucleus. | | **Thickness ~ 1/3-1/2 of squamous cell nucleus. |
| **Should be within (squamous) epithelium. | | **Should be within (squamous) epithelium. |
| ***On top of epithelium does not count,<ref>ALS. 4 October 2010.</ref> i.e. it is likely an artifact. | | *Superficial inflammation - esp. [[neutrophils]] - '''important'''. |
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| Image: [http://en.wikipedia.org/wiki/File:Esophageal_candidiasis_(2)_PAS_stain.jpg Esophageal candidiasis (WC)].
| | Notes: |
| | *On top of epithelium does not count,<ref>ALS. 4 October 2010.</ref> i.e. it is likely an artifact. |
| | *Bacilli and cocci may accompany the candida. They are typically ignored. |
| | |
| | DDx: |
| | *[[Acute esophagitis]] - no candida seen. |
| | |
| | =====Image===== |
| | <gallery> |
| | Image:Esophageal_candidiasis_(2)_PAS_stain.jpg | Esophageal candidiasis. (WC) |
| | </gallery> |
| | |
| | ====Sign out==== |
| | <pre> |
| | ESOPHAGUS, BIOPSY: |
| | - ESOPHAGITIS WITH FUNGAL ORGANISMS CONSISTENT WITH CANDIDA. |
| | </pre> |
| | |
| | <pre> |
| | ESOPHAGUS, BIOPSY: |
| | - ACUTE ESOPHAGITIS WITH FUNGAL ORGANISMS CONSISTENT WITH CANDIDA. |
| | - NEGATIVE FOR INTESTINAL METAPLASIA. |
| | - NEGATIVE FOR DYSPLASIA. |
| | </pre> |
|
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| ===Cytomegalovirus esophagitis=== | | ===Cytomegalovirus esophagitis=== |
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| ===Herpes esophagitis=== | | ===Herpes esophagitis=== |
| ====General====
| | {{Main|Herpes esophagitis}} |
| Etiology:
| |
| *[[Herpes simplex virus]].
| |
| | |
| ====Gross/endoscopic====
| |
| Features:
| |
| *Ulcers with a "punched-out" appearance with a brown/red edge.
| |
| | |
| Images:
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| *[http://library.med.utah.edu/WebPath/GIHTML/GI003.html Herpes esophagitis - gross (utah.edu)].
| |
| *[http://www.gastrohep.com/images/image.asp?id=648 Herpes esophagitis - endoscopy (gastrohep.com)].
| |
| *[http://commons.wikimedia.org/wiki/File:Herpes_esophagitis.JPG Herpes eosphagitis - endoscopy (WC)].
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|
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| ====Microscopic====
| |
| Features (3 Ms):
| |
| *'''M'''oulding.
| |
| *'''M'''ultinucleation.
| |
| *'''M'''argination of chromatin.
| |
| | |
| Images:
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| *[http://commons.wikimedia.org/wiki/File:Herpes_esophagitis_-_very_high_mag.jpg HSV esophagitis - very high mag. (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Herpes_esophagitis_-_intermed_mag.jpg HSV esophagitis - intermed. mag. (WC)].
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| ===Human papillomavirus esophagitis=== | | ===Human papillomavirus esophagitis=== |
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| *[http://commons.wikimedia.org/wiki/File:Low-grade_sil_and_endocx.jpg LSIL & endocervix (WC)]. | | *[http://commons.wikimedia.org/wiki/File:Low-grade_sil_and_endocx.jpg LSIL & endocervix (WC)]. |
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| =Other= | | =Non-neoplastic disease= |
| | The group of conditions doesn't fit neatly with the others. It is a mixture of different non-neoplastic conditions. |
| ==Gastroesophageal reflux disease== | | ==Gastroesophageal reflux disease== |
| ===General===
| | *Abbreviated ''GERD'' or ''GORD'' (gastro-oesophageal reflux disease). |
| *Abbreviated ''GERD'' and ''GORD'' (gastro-oesophageal reflux disease). | | *[[AKA]] ''reflux esophagitis''. |
| | | {{Main|Gastroesophageal reflux disease}} |
| Clinical:
| |
| *Treated with proton pump inhibitors (PPIs). | |
| | |
| ===Microscopic===
| |
| Features:
| |
| #Basal cell hyperplasia;<ref name=pmid16707971>{{Cite journal | last1 = Steiner | first1 = SJ. | last2 = Kernek | first2 = KM. | last3 = Fitzgerald | first3 = JF. | title = Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis. | journal = J Pediatr Gastroenterol Nutr | volume = 42 | issue = 5 | pages = 506-9 | month = May | year = 2006 | doi = 10.1097/01.mpg.0000221906.06899.1b | PMID = 16707971 }}</ref> > 3 cells thick ''or'' >15% of epithelial thickness.
| |
| #Papillae elongated; papillae reach into the top 1/3 of the epithelial layer.<ref name=Ref_PBoD804>{{Ref PBoD|804}}</ref>
| |
| #Inflammation, esp. eosinophils, lymphocytes with convoluted nuclei ("squiggle cells").
| |
| #+/-Spongiosis.
| |
| #+/-Apoptotic cells.<ref name=pmid9926792>{{cite journal |author=Wetscher GJ, Schwelberger H, Unger A, ''et al.'' |title=Reflux-induced apoptosis of the esophageal mucosa is inhibited in Barrett's epithelium |journal=Am. J. Surg. |volume=176 |issue=6 |pages=569–73 |year=1998 |month=December |pmid=9926792 |doi= |url=}}</ref>
| |
| | |
| Notes:
| |
| *Intraepithelial cells with irregular nuclear contours, "squiggle cells" (T lymphocytes<ref name=pmid7587806>PMID: 7587806.</ref>), may mimic [[neutrophil]]s.
| |
| | |
| DDx:
| |
| *[[Eosinophilic esophagitis]] - characterized by similar histomorphologic features. The key difference is: more [[eosinophil]]s.
| |
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| Images:
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| *[http://www.archivesofpathology.org/action/showFullPopup?id=i1543-2165-134-6-815-f03&doi=10.1043%2F1543-2165-134.6.815 EE versus GERD (archivesofpathology.org)].<ref name=pmid20524860/>
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| ==Eosinophilic esophagitis== | | ==Eosinophilic esophagitis== |
| *Abbreviated ''EE''. | | *Abbreviated ''EE''. |
| ===General===
| | {{Main|Eosinophilic esophagitis}} |
| *The current thinking is that it is a clinico-pathologic diagnosis.<ref name=pmid20524860>{{Cite journal | last1 = Genevay | first1 = M. | last2 = Rubbia-Brandt | first2 = L. | last3 = Rougemont | first3 = AL. | title = Do eosinophil numbers differentiate eosinophilic esophagitis from gastroesophageal reflux disease? | journal = Arch Pathol Lab Med | volume = 134 | issue = 6 | pages = 815-25 | month = Jun | year = 2010 | doi = 10.1043/1543-2165-134.6.815 | PMID = 20524860 | url = http://www.archivesofpathology.org/doi/full/10.1043/1543-2165-134.6.815 }}</ref>
| |
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| Clinical:
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| *Dyspepsia.
| |
| **Often mimics gastroesophageal reflux (GERD).<ref name=pmid19596009>{{Cite journal | last1 = Rothenberg | first1 = ME. | title = Biology and treatment of eosinophilic esophagitis. | journal = Gastroenterology | volume = 137 | issue = 4 | pages = 1238-49 | month = Oct | year = 2009 | doi = 10.1053/j.gastro.2009.07.007 | PMID = 19596009 }}
| |
| </ref>
| |
| *Dysphagia.<ref>URL: [http://www.medicinenet.com/eosinophilic_esophagitis/page2.htm#tocc http://www.medicinenet.com/eosinophilic_esophagitis/page2.htm#tocc]. Accessed on: 1 December 2009.</ref>
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| Treatment:
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| *Avoid exacerbating antigens.
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| *Topical corticosteroids, e.g. fluticasone.
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| Biopsies:
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| *Should be taken from: upper, mid, lower and submitted in separate containers (eosinophilia present through-out-- to differentiate from GERD).
| |
| | |
| Associations:
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| *Atopy.<ref name=Ref_GLP19>{{Ref GLP|19}}</ref>
| |
| *[[Celiac disease]].<ref name=pmid19841598>{{cite journal |author=Leslie C, Mews C, Charles A, Ravikumara M |title=Celiac disease and eosinophilic esophagitis: a true association |journal=J. Pediatr. Gastroenterol. Nutr. |volume=50 |issue=4 |pages=397–9 |year=2010 |month=April |pmid=19841598 |doi=10.1097/MPG.0b013e3181a70af4 |url=}}</ref>
| |
| *Oral antigens, i.e. particular foods.<ref name=pmid19596009/>
| |
| *Familial association.<ref name=pmid19596009/>
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| | |
| ===Gross/endoscopic===
| |
| *'''Trachealization'''; eosphagus looks like trachea.<ref name=pmid19636182>{{Cite journal | last1 = Al-Hussaini | first1 = AA. | last2 = Semaan | first2 = T. | last3 = El Hag | first3 = IA. | title = Esophageal trachealization: a feature of eosinophilic esophagitis. | journal = Saudi J Gastroenterol | volume = 15 | issue = 3 | pages = 193-5 | month = | year = | doi = 10.4103/1319-3767.54747 | PMID = 19636182 }}
| |
| </ref>
| |
| **[[AKA]] ''feline esophagus''.<ref>URL: [http://www.ajronline.org/cgi/reprint/164/4/900.pdf http://www.ajronline.org/cgi/reprint/164/4/900.pdf]. Accessed on: 4 October 2010.</ref>
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| *White.
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| DDx (endoscopic):
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| *[[Candida esophagitis]]
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| Image:
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| *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841420/figure/F0001/ Trachealization - radiograph (nih.gov)].
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| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_GLP19>{{Ref GLP|19}}</ref>
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| *Mucosa with "abundant eosinophils".
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| *Basal cell hyperplasia.
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| **Three cells thick ''or'' >15% of epithelial thickness.
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| *Papillae elongated.
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| **Papillae that reach into the top 1/3 of the epithelial layer - definition for GERD.<ref name=Ref_PBoD804>{{Ref PBoD|804}}</ref>
| |
| | |
| Notes "abundant eosinophils":
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| *Criteria for number of eosinophils/area is '''''highly variable'''''; there is a 23X fold variation in published values and only 11% of studies actually define an area (most studies, embarassing for pathologists that understand this issue, only give the number of eosinophils per "HPF")!<ref name=pmid17617209>{{cite journal |author=Dellon ES, Aderoju A, Woosley JT, Sandler RS, Shaheen NJ |title=Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review |journal=Am. J. Gastroenterol. |volume=102 |issue=10 |pages=2300–13 |year=2007 |month=October |pmid=17617209 |doi=10.1111/j.1572-0241.2007.01396.x |url=}}</ref>
| |
| **The group that published the article cited above did another one... <ref name=pmid19830560>PMID 19830560.</ref>
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| *The most commonly reported cut points are 15, 20 and 24 eosinophils/HPF, without defining HPF.<ref name=pmid17617209/>
| |
| **The ''Foundation Series'' book<ref name=Ref_GLP19>{{Ref GLP|19}}</ref> says: "> 20/HPF"; [[VL]] sees this definition as garbage, as "HPF" is not defined (see [[HPFitis]]).
| |
| **There is a consensus paper<ref>{{cite journal |author=Furuta GT, Liacouras CA, Collins MH, ''et al.'' |title=Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment |journal=Gastroenterology |volume=133 |issue=4 |pages=1342–63 |year=2007 |month=October |pmid=17919504 |doi=10.1053/j.gastro.2007.08.017 |url=}}</ref> that makes note of [[HPFitis]]... and then goes on to ignore to whole issue by defining EE as 15/HPF. It blows my mind that the people could be so will fully blind and that the idiotic reviewers didn't understand this.
| |
| **Most resident microscopes at the Toronto teaching hospitals have 22 mm eye pieces and have for their highest magnification objective a 40X. De facto, this means most people in Toronto are using the Liacouras ''et al.'' definition.<ref name=pmid16361045>{{cite journal |author=Liacouras CA, Spergel JM, Ruchelli E, ''et al.'' |title=Eosinophilic esophagitis: a 10-year experience in 381 children |journal=Clin. Gastroenterol. Hepatol. |volume=3 |issue=12 |pages=1198–206 |year=2005 |month=December |pmid=16361045 |doi= |url=}}</ref>
| |
| | |
| DDx:<ref name=Ref_Odze244>{{Ref Odze|244}}</ref>
| |
| *[[Gastroesophageal reflux disease]] - no mid and proximal involvement.
| |
| *[[Infectious esophagitis]].
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| *Eosinophilic gastroenteritis.
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| *Hypereosinophilic syndrome.
| |
| | |
| Images:
| |
| *[http://commons.wikimedia.org/w/index.php?title=File:Eosinophilic_esophagitis_-_2_-_very_high_mag.jpg Eosinophilic esophagitis - very high mag. (WC)].
| |
| *[http://commons.wikimedia.org/w/index.php?title=File:Eosinophilic_esophagitis_-_2_-_high_mag.jpg Eosinophilic esophagitis - high mag. (WC)].
| |
| *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841420/figure/F0003/ Eosinophilic esophagitis (nih.gov)].
| |
| *[http://www.archivesofpathology.org/action/showFullPopup?id=i1543-2165-134-6-815-f03&doi=10.1043%2F1543-2165-134.6.815 EE versus GERD (archivesofpathology.org)].<ref name=pmid20524860/>
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| ==Erosive esophagitis== | | ==Erosive esophagitis== |
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| Classic causes: | | Classic causes: |
| *Alendronate (Fosamax) - for [[osteoporosis]]. | | *Alendronate (Fosamax) - for [[osteoporosis]]. |
| *Iron (can be demonstrated with Prussian blue stain). | | *Iron - can be demonstrated with [[Prussian blue stain]]. |
| *Doxycycline. | | *Doxycycline. |
|
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|
| =Preneoplastic= | | ==Esophageal varices== |
| ==Barrett esophagus==
| | {{Main|Esophageal varices}} |
| *Abbreviated ''BE''.
| |
| ===General===
| |
| *Diagnosis is made by '''clinicans ''not'' pathologists'''.
| |
| **A common histologic correlate is metaplastic transformation of stratified squamous epithelium to simple columnar epithelium with goblet cells.
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| ***There is disagreement whether goblet cells are required for the diagnosis.<ref name=pmid19623166>{{Cite journal | last1 = Riddell | first1 = RH. | last2 = Odze | first2 = RD. | title = Definition of Barrett's esophagus: time for a rethink--is intestinal metaplasia dead? | journal = Am J Gastroenterol | volume = 104 | issue = 10 | pages = 2588-94 | month = Oct | year = 2009 | doi = 10.1038/ajg.2009.390 | PMID = 19623166 }}</ref>
| |
| ****One large study suggests that goblets cells are only absent due to undersampling.<ref name=pmid21959311>{{Cite journal | last1 = Chandrasoma | first1 = P. | last2 = Wijetunge | first2 = S. | last3 = DeMeester | first3 = S. | last4 = Ma | first4 = Y. | last5 = Hagen | first5 = J. | last6 = Zamis | first6 = L. | last7 = DeMeester | first7 = T. | title = Columnar-lined esophagus without intestinal metaplasia has no proven risk of adenocarcinoma. | journal = Am J Surg Pathol | volume = 36 | issue = 1 | pages = 1-7 | month = Jan | year = 2012 | doi = 10.1097/PAS.0b013e31822a5a2c | PMID = 21959311 }}</ref>
| |
| *Associated with chronic reflux - ''see: [[gastroesophageal reflux disease]]''.
| |
| | |
| Significance of Barrett's esophagus:
| |
| *Increased risk of adenocarcinoma of the esophagus.
| |
| **Need on-going surveillance, i.e. long term follow-up/repeat esophagogastroduodenoscopy.
| |
|
| |
|
| ===Gross=== | | ==Acute esophagitis== |
| *Red/light brown esophageal mucosa.
| | {{Main|Acute esophagitis}} |
| **Normal mucosa = light pink.
| |
|
| |
|
| Image:
| | ==Benign esophageal stricture== |
| *[http://commons.wikimedia.org/wiki/File:Barretts_esophagus.jpg Endoscopic image of BE (WC)].
| | {{Main|Esophageal stricture}} |
|
| |
|
| ===Microscopic=== | | ==Esophageal duplication cyst== |
| Features:
| | {{Main|Foregut duplication cyst}} |
| *Columnar epithelium.
| |
| *Goblets cells - '''key feature'''.
| |
| *+/-Mild hyperchromasia.
| |
| *+/-Reactive squamous epithelium suggestive of reflux.
| |
|
| |
|
| Images:
| | ==Zenker's diverticulum== |
| *[http://commons.wikimedia.org/wiki/File:Barretts_alcian_blue.jpg Barrett's esophagus - alcian blue (WC)]. | | {{Main|Zenker's diverticulum}} |
| | *[[AKA]] ''cricopharyngeal diverticulum'', ''pharyngoesophageal diverticulum'' and ''hypopharyngeal diverticulum''. |
|
| |
|
| ===Stains=== | | ==Radiation esophagitis== |
| *Alcian blue - goblet cells +ve.
| | {{Main|Radiation esophagitis}} |
|
| |
|
| ===Sign-out=== | | =Preneoplastic= |
| <pre>
| | ==Barrett esophagus== |
| ESOPHAGUS, DISTAL, BIOPSY:
| | {{Main|Barrett esophagus}} |
| - COLUMNAR EPITHELIUM WITH MODERATE CHRONIC INFLAMMATION AND INTESTINAL METAPLASIA, SEE COMMENT.
| |
| - SQUAMOUS EPITHELIUM WITHIN NORMAL LIMITS.
| |
| - NEGATIVE FOR DYSPLASIA AND MALIGNANCY.
| |
|
| |
|
| Comment:
| | =Neoplastic= |
| The finding is consistent with Barrett's esophagus in the appropriate endoscopic setting. | | ==Columnar dysplasia of the esophagus== |
| </pre> | | *[[AKA]] ''esophageal columnar dysplasia'', abbreviated ''ECD''.<ref name=pmid21809994>{{Cite journal | last1 = Feng | first1 = W. | last2 = Zhou | first2 = Z. | last3 = Peters | first3 = JH. | last4 = Khoury | first4 = T. | last5 = Zhai | first5 = Q. | last6 = Wei | first6 = Q. | last7 = Truong | first7 = CD. | last8 = Song | first8 = SW. | last9 = Tan | first9 = D. | title = Expression of insulin-like growth factor II mRNA-binding protein 3 in human esophageal adenocarcinoma and its precursor lesions. | journal = Arch Pathol Lab Med | volume = 135 | issue = 8 | pages = 1024-31 | month = Aug | year = 2011 | doi = 10.5858/2009-0617-OAR2 | PMID = 21809994 }}</ref> |
| | *[[AKA]] ''dysplasia in the columnar-lined esophagus''.<ref>{{Cite journal | last1 = Levine | first1 = DS. | title = Management of dysplasia in the columnar-lined esophagus. | journal = Gastroenterol Clin North Am | volume = 26 | issue = 3 | pages = 613-34 | month = Sep | year = 1997 | doi = | PMID = 9309409 }}</ref> |
| | * [[AKA]] ''columnar epithelial dysplasia''.<ref name=pmid3825997>{{Cite journal | last1 = Hamilton | first1 = SR. | last2 = Smith | first2 = RR. | title = The relationship between columnar epithelial dysplasia and invasive adenocarcinoma arising in Barrett's esophagus. | journal = Am J Clin Pathol | volume = 87 | issue = 3 | pages = 301-12 | month = Mar | year = 1987 | doi = | PMID = 3825997 }}</ref> |
| | {{Main|Columnar dysplasia of the esophagus}} |
|
| |
|
| =Neoplastic= | | ==Squamous dysplasia of the esophagus== |
| ==Columnar dysplasia== | | *[[AKA]] ''esophageal squamous dysplasia''. |
| ===General=== | | ===General=== |
| | *Precursor of [[esophageal squamous cell carcinoma]].<ref name=pmid11936262>{{Cite journal | last1 = Dry | first1 = SM. | last2 = Lewin | first2 = KJ. | title = Esophageal squamous dysplasia. | journal = Semin Diagn Pathol | volume = 19 | issue = 1 | pages = 2-11 | month = Feb | year = 2002 | doi = | PMID = 11936262 }}</ref> |
| | *Common in China.<ref name=pmid11936262/> |
| | *Not very common in North America. |
|
| |
|
| ====Classification==== | | ===Microscopic=== |
| *Indefinite for dysplasia. | | Features: |
| **Diagnose used in the context of uncertainty (like ''[[gynecologic cytopathology|ASCUS]]'' and ''[[prostate gland|ASAP]]''); usually used in the context of inflammation. | | *Squamous cell nuclear atypia. |
| *Low grade dysplasia.
| | *Lack of maturation to the surface. |
| *High grade dysplasia.
| |
|
| |
|
| ====Management====
| | Note: |
| Low grade dysplasia.
| | *Grading differences between Western pathologists and those of the east.<ref name=pmid11936262/> |
| *Follow-up. | |
|
| |
|
| High grade dysplasia.
| | DDx: |
| *Endoscopic mucosal resection.<ref name=pmid19306943>{{cite journal |author=Sampliner RE |title=Endoscopic Therapy for Barrett's Esophagus |journal=Clin. Gastroenterol. Hepatol. |volume= |issue= |pages= |year=2009 |month=March |pmid=19306943 |doi=10.1016/j.cgh.2009.03.011 |url=}}</ref> | | *Reactive changes. |
| *Surgical resection. | | *[[Esophageal squamous cell carcinoma]]. |
|
| |
|
| ===Microscopic=== | | ====Images==== |
| Features to assess:<ref name=Ref_GLP46>{{Ref GLP|46}}</ref>
| | A set of cases from Japan:<ref name=pmid23330004>{{Cite journal | last1 = Terada | first1 = T. | title = A clinicopathologic study of esophageal 860 benign and malignant lesions in 910 cases of consecutive esophageal biopsies. | journal = Int J Clin Exp Pathol | volume = 6 | issue = 2 | pages = 191-8 | month = | year = 2013 | doi = | PMID = 23330004 }}</ref> |
| # Lack of surface maturation.
| | *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig05/ Mild squamous dysplasia (nih.gov)]. |
| #*Lack of lighter staining at surface.
| | *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig06/ Moderate squamous dysplasia (nih.gov)]. |
| #*Nuclear crowding at surface.
| | *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig07/ Severe squamous dysplasia (nih.gov)]. |
| #*Nuclei at the surface not smaller.
| | *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig08/ Carcinoma in situ (nih.gov)]. |
| # Architecture - esp. at low power.
| | *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig09/ Squamous cell carcinoma of the esophagus (nih.gov)]. |
| #* Glands not round.
| |
| #** Low-grade feature: gland budding.
| |
| #** High-grade features: cribriforming, cystic dilation, necrotic debris.
| |
| #* Gland density:
| |
| #** Increased & round - think low-grade dysplasia.
| |
| #** Increased & irregular - think high-grade dysplasia.
| |
| # Cytology, esp. at high magnification.
| |
| #* Nuclear abnormalities in: size, staining, shape.
| |
| #* Loss of "nuclear polarity" = high-grade feature
| |
| #** Loss of palisaded appearance, rounding-up of nuclei.
| |
| # Inflammation, erosions & ulceration.
| |
| #* Marked inflammation should prompt consideration of knocking down the diagnosis one step, i.e. low-grade becomes indefinite ''or'' high-grade becomes low-grade.
| |
|
| |
|
| Negatives:
| | ===IHC=== |
| #No desmoplasia.
| | *Ki-67 may be useful:<ref name=pmid21420715>{{Cite journal | last1 = Wang | first1 = WC. | last2 = Wu | first2 = TT. | last3 = Chandan | first3 = VS. | last4 = Lohse | first4 = CM. | last5 = Zhang | first5 = L. | title = Ki-67 and ProExC are useful immunohistochemical markers in esophageal squamous intraepithelial neoplasia. | journal = Hum Pathol | volume = 42 | issue = 10 | pages = 1430-7 | month = Oct | year = 2011 | doi = 10.1016/j.humpath.2010.12.009 | PMID = 21420715 }}</ref> |
| #*Stromal fibrotic reaction to the tumour.
| | **Reactive changes/normal: ~98% negative, ~2% intermediate. |
| #**Desmoplasia is rare in the superficial esophagus.<ref name=Ref_GLP49>{{Ref GLP|49}}</ref>
| | **Low-grade esophageal squamous intraepithelial neoplasia (LGESIN): ~80% intermediate, ~20% negative. |
| #No single cells.
| | **High-grade esophageal squamous intraepithelial neoplasia (HGESIN): ~37% intermediate, ~63% strong. |
| #No extensive back-to-back glands.
| |
| | |
| Notes:
| |
| *Changes similar to those see in colorectal tubular adenomas; however, what would be low-grade dysplasia in the rectum is high-grade dysplasia in the esophagus.
| |
| *Presence of goblet cells is mildly reassuring its not dysplasia.<ref>GAG. January 2009.</ref> | |
| *Desmoplasia present = invasive adenocarcinoma.<ref name=Ref_GLP54>{{Ref GLP|54}}</ref> | |
|
| |
|
| Image:
| | Definitions:<ref name=pmid21420715/> |
| *[http://www.hopkins-gi.org/Upload/200708141549_007658241.jpg Barrett's, Low-grade, High-grade (hopkins-gi.org)].<ref>URL: [http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Disease_ID=46159D68-6ED3-4F76-895B-99D8BBBB46EF&GDL_DC_ID=E25BDF77-223D-4B6F-9700-5BE41DBDE28B http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Disease_ID=46159D68-6ED3-4F76-895B-99D8BBBB46EF&GDL_DC_ID=E25BDF77-223D-4B6F-9700-5BE41DBDE28B]. Accessed on: 7 August 2011.</ref> | | *Negative defined as: < 25% of epithelium +ve ''and'' staining only in lower quarter of epithelium. |
| | *Intermediate defined: >=25% and <=50% of epithelium +ve ''and'' only in the lower half of the epithelium. |
| | *Strong defined: >50% of epithelium +ve ''or'' upper half of epithelium. |
|
| |
|
| ==Leiomyoma of the esophagus== | | ==Leiomyoma of the esophagus== |
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| ==Squamous cell carcinoma of the esophagus== | | ==Squamous cell carcinoma of the esophagus== |
| *[[AKA]] ''esophageal squamous cell carcinoma'', abbreviated ''esophageal SCC''. | | *[[AKA]] ''esophageal squamous cell carcinoma'', abbreviated ''esophageal SCC''. |
| {{Main|Squamous carcinoma}} | | {{Main|Squamous cell carcinoma of the esophagus}} |
| ===General===
| |
| *Like squamous cell carcinoma elsewhere.
| |
| | |
| Risk factors:<ref name=Ref_APBR104>{{Ref APBR|104 Q1}}</ref>
| |
| *Alcohol consumption.
| |
| *Tobacco use.
| |
| *Food with nitrosamines.
| |
| *Burning-hot beverages.
| |
| | |
| Note:
| |
| *Reflux is ''not'' a risk factor for esophageal SCC.
| |
| | |
| ===Microscopic===
| |
| :See ''[[Squamous carcinoma]]''.
| |
| | |
| Note:
| |
| *Just to make things confusing, the ''Staging'' of early SCC differs from that of early adenocarcinoma!
| |
|
| |
|
| ==Esophageal adenocarcinoma== | | ==Esophageal adenocarcinoma== |
| *[[AKA]] ''adenocarcinoma of the esophagus''. | | *[[AKA]] ''adenocarcinoma of the esophagus''. |
| | | {{Main|Esophageal adenocarcinoma}} |
| ===General===
| |
| *Often a prognosis poor - as diagnosed in a late stage.
| |
| *May be difficult to distinguish from adenocarcinoma of the stomach.
| |
| **By convention (in the ''[[CAP checklist]]'') gastroesophageal junction carcinomas are staged as esophageal carcinomas.<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Esophagus_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Esophagus_11protocol.pdf]. Accessed on: 6 April 2012.</ref>
| |
| | |
| ====Tx====
| |
| *Adenocarcinoma in situ (AIS) - may be treated with endoscopic mucosal resection & follow-up.<ref name=pmid19306943/>
| |
| *Surgery - esophagectomy.
| |
| | |
| ====Esophagus vs. stomach====
| |
| The convention is it's esophageal if both of the following are true:<ref name=Ref_WMSP168>{{Ref WMSP|168}}</ref>
| |
| #Epicenter of tumour is in the esophagus.
| |
| #Barrett's mucosa is present.
| |
| | |
| ===Microscopic===
| |
| Features:
| |
| *Adenocarcinoma:
| |
| **Cell clusters that form glands.
| |
| **Nuclear atypia of malignancy:
| |
| ***Size variation.
| |
| ***Shape variation.
| |
| ***Staining variation.
| |
| **Mitoses common.
| |
| | |
| Images:
| |
| *[http://commons.wikimedia.org/wiki/File:Esophageal_adenocarcinoma_-_very_low_mag.jpg Esophageal adenocarcinoma - very low mag. (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Esophageal_adenocarcinoma_-_intermed_mag.jpg Esophageal adenocarcinoma - intermed. mag. (WC)].
| |
|
| |
| ====Grading====
| |
| Graded like other adenocarcinoma:<ref name=Ref_WMSP168>{{Ref WMSP|168}}</ref>
| |
| *>95 % of tumour in glandular arrangement = ''well-differentiated''.
| |
| *95-50% of tumour in glandular arrangement= ''moderately-differentiated''.
| |
| *<50% of tumour in glandular arrangment = ''poorly-differentiated''.
| |
| | |
| ====Staging====
| |
| Early esophageal adenocarcinoma has its own staging system:<ref>{{Cite journal | last1 = Pech | first1 = O. | last2 = May | first2 = A. | last3 = Rabenstein | first3 = T. | last4 = Ell | first4 = C. | title = Endoscopic resection of early oesophageal cancer. | journal = Gut | volume = 56 | issue = 11 | pages = 1625-34 | month = Nov | year = 2007 | doi = 10.1136/gut.2006.112110 | PMID = 17938435 | PMC = 2095648 }}</ref><ref>{{Cite journal | last1 = Thosani | first1 = N. | last2 = Singh | first2 = H. | last3 = Kapadia | first3 = A. | last4 = Ochi | first4 = N. | last5 = Lee | first5 = JH. | last6 = Ajani | first6 = J. | last7 = Swisher | first7 = SG. | last8 = Hofstetter | first8 = WL. | last9 = Guha | first9 = S. | title = Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis. | journal = Gastrointest Endosc | volume = | issue = | pages = | month = Nov | year = 2011 | doi = 10.1016/j.gie.2011.09.016 | PMID = 22115605 | URL = http://www.sciencedirect.com/science/article/pii/S0016510711022048 }}</ref>
| |
| *M1 = lamina propria.
| |
| *M2 = superficial muscularis mucosae.
| |
| *M3 = submucosa.
| |
| *M4 = muscularis propria.
| |
| | |
| ===IHC===
| |
| *CK7 +ve.
| |
| *CK20 +ve.
| |
| | |
| To rule-out SCC:
| |
| *p63 -ve.
| |
| *HWMK -ve.
| |
|
| |
|
| =Weird stuff= | | =Weird stuff= |
Line 618: |
Line 471: |
| *Granular cell tumour. | | *Granular cell tumour. |
| *Squamous papilloma - koilocytes. | | *Squamous papilloma - koilocytes. |
| *Heterotopic gastric mucosa ("inlet patch") - benign appearing gastric mucosa. | | *Heterotopic gastric mucosa ("[[inlet patch]]") - benign appearing gastric mucosa. |
|
| |
|
| ==Granular cell tumour== | | ==Granular cell tumour== |
Line 631: |
Line 484: |
| *Usu. bland (cytologically non-malignant) nuclei. | | *Usu. bland (cytologically non-malignant) nuclei. |
|
| |
|
| Images: | | ====Images==== |
| | *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544238/figure/fig04/ GCT of the esophagus (nih.gov)].<ref name=pmid23330004>{{Cite journal | last1 = Terada | first1 = T. | title = A clinicopathologic study of esophageal 860 benign and malignant lesions in 910 cases of consecutive esophageal biopsies. | journal = Int J Clin Exp Pathol | volume = 6 | issue = 2 | pages = 191-8 | month = | year = 2013 | doi = | PMID = 23330004 }}</ref> |
| *[http://commons.wikimedia.org/wiki/File:Granular_cell_tumor_(3)_skin.jpg GCT - skin (WC)]. | | *[http://commons.wikimedia.org/wiki/File:Granular_cell_tumor_(3)_skin.jpg GCT - skin (WC)]. |
| *[http://commons.wikimedia.org/wiki/File:Granular_cell_tumor_(4)_S-100.JPG GCT - S100 (WC)]. | | *[http://commons.wikimedia.org/wiki/File:Granular_cell_tumor_(4)_S-100.JPG GCT - S100 (WC)]. |
Line 639: |
Line 493: |
|
| |
|
| ===General=== | | ===General=== |
| *Rare & benign condition that resolves without last pathology.<ref name=pmid19809273/> | | *Rare & benign condition that resolves without lasting pathology.<ref name=pmid19809273/> |
| **Case report - chronic with strictures.<ref>{{Cite journal | last1 = Coppola | first1 = D. | last2 = Lu | first2 = L. | last3 = Boyce | first3 = HW. | title = Chronic esophagitis dissecans presenting with esophageal strictures: a case report. | journal = Hum Pathol | volume = 31 | issue = 10 | pages = 1313-7 | month = Oct | year = 2000 | doi = 10.1053/hupa.2000.18470 | PMID = 11070124 }} | | **Case report - chronic with strictures.<ref>{{Cite journal | last1 = Coppola | first1 = D. | last2 = Lu | first2 = L. | last3 = Boyce | first3 = HW. | title = Chronic esophagitis dissecans presenting with esophageal strictures: a case report. | journal = Hum Pathol | volume = 31 | issue = 10 | pages = 1313-7 | month = Oct | year = 2000 | doi = 10.1053/hupa.2000.18470 | PMID = 11070124 }} |
| </ref> | | </ref> |
Line 652: |
Line 506: |
|
| |
|
| ==Glycogenic acanthosis of the esophagus== | | ==Glycogenic acanthosis of the esophagus== |
| | {{Main|Glycogenic acanthosis of the esophagus}} |
| | |
| | ==Achalasia== |
| | {{main|Achalasia}} |
| | |
| | ==Esophageal inlet patch== |
| | *[[AKA]] ''inlet patch'', [[AKA]] ''cervical inlet patch''. |
| ===General=== | | ===General=== |
| *Uncommon.
| | *Benign and likely not of any significance.<ref name=pmid23372354/> |
| *Benign. | |
| *Possible association with ingestion of hot liquids.<ref name=pmid20524767/>
| |
|
| |
|
| ===Gross/endoscopic=== | | ===Gross=== |
| *Distinctive endoscopic appearance - grey/white raised lesion.<ref name=pmid20524767>{{Cite journal | last1 = Lopes | first1 = S. | last2 = Figueiredo | first2 = P. | last3 = Amaro | first3 = P. | last4 = Freire | first4 = P. | last5 = Alves | first5 = S. | last6 = Cipriano | first6 = MA. | last7 = Gouveia | first7 = H. | last8 = Sofia | first8 = C. | last9 = Correia-Leitão | first9 = M. | title = Glycogenic acanthosis of the esophagus: an unusually endoscopic appearance. | journal = Rev Esp Enferm Dig | volume = 102 | issue = 5 | pages = 341-2 | month = May | year = 2010 | doi = | PMID = 20524767 | URL = http://www.grupoaran.com/mrmUpdate/lecturaPDFfromXML.asp?IdArt=4618820&TO=RVN&Eng=1 }}</ref> | | *Proximal esophagus - salmon coloured lesion.<ref name=pmid23372354>{{Cite journal | last1 = Chong | first1 = VH. | title = Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus. | journal = World J Gastroenterol | volume = 19 | issue = 3 | pages = 331-8 | month = Jan | year = 2013 | doi = 10.3748/wjg.v19.i3.331 | PMID = 23372354 }}</ref> |
|
| |
|
| ===Microscopic=== | | ===Microscopic=== |
| Features:<ref name=pmid20524767/> | | Features: |
| *Squamous epithelium with:
| | *Gastric mucosa.<ref name=pmid22091379/> |
| **Superficial clearing of the cytoplasm. | | |
| **Thickening.
| | Image: |
| | *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3197178/figure/fig4/ Esophageal inlet patch (nih.gov)].<ref name=pmid22091379>{{Cite journal | last1 = Behrens | first1 = C. | last2 = Yen | first2 = PP. | title = Esophageal inlet patch. | journal = Radiol Res Pract | volume = 2011 | issue = | pages = 460890 | month = | year = 2011 | doi = 10.1155/2011/460890 | PMID = 22091379 }}</ref> |
|
| |
|
| Images:
| | ===Sign out=== |
| *[http://scielo.isciii.es/pdf/diges/v102n5/carta3.pdf Glycogenic acanthosis (isciii.es)].
| | <pre> |
| | Esophagus at 22 cm, Biopsy: |
| | - Gastric type mucosa with mild chronic inactive inflammation, see comment. |
| | - Scant unremarkable squamous epithelium. |
| | - NEGATIVE for intestinal metaplasia. |
| | - NEGATIVE for dysplasia. |
|
| |
|
| ==Achalasia==
| | Comment: |
| ===General===
| | This is in keeping with an "inlet patch", also known as "heterotopic gastric mucosal patch of the proximal esophagus". |
| *Uncommon.
| | </pre> |
| *Risk factor for [[squamous cell carcinoma]] (in men and women) and [[esophageal adenocarcinoma|adenocarcinoma]] (in men).<ref>{{Cite journal | last1 = Zendehdel | first1 = K. | last2 = Nyrén | first2 = O. | last3 = Edberg | first3 = A. | last4 = Ye | first4 = W. | title = Risk of esophageal adenocarcinoma in achalasia patients, a retrospective cohort study in Sweden. | journal = Am J Gastroenterol | volume = 106 | issue = 1 | pages = 57-61 | month = Jan | year = 2011 | doi = 10.1038/ajg.2010.449 | PMID = 21212754 }}</ref>
| |
|
| |
|
| ===Microscopic=== | | ==Squamous papilloma of the esophagus== |
| Features:
| | {{Main|Squamous papilloma of the esophagus}} |
| *Mucosa usually normal.<ref name=pmid16128783>{{Cite journal | last1 = Kjellin | first1 = AP. | last2 = Ost | first2 = AE. | last3 = Pope | first3 = CE. | title = Histology of esophageal mucosa from patients with achalasia. | journal = Dis Esophagus | volume = 18 | issue = 4 | pages = 257-61 | month = | year = 2005 | doi = 10.1111/j.1442-2050.2005.00478.x | PMID = 16128783 }}</ref>
| |
|
| |
|
| =See also= | | =See also= |
Line 686: |
Line 549: |
|
| |
|
| [[Category:Gastrointestinal pathology]] | | [[Category:Gastrointestinal pathology]] |
| | [[Category:Esophagus|Esophagus]] |