Esophagus

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.

Normal

General:

• Stratified squamous non-keratinized epithelium.

Normal (esophageal) squamous epithelium:

• Should "mature" to the surface like good stratified squamous epithelium does.
  • No nuclei at luminal surface.
  • Cells should become less hyperchromatic as you go toward the lumen.
  • Mitoses should be rare and should NOT be above the basal layer.
• Inflammatory cells should be very rare.

Diagnoses

Common

• Normal.
• Metaplasia (Barrett's esophagus).
• Dysplasia.
• Adenocarcinoma.

Less common

• Squamous cell carcinoma.
• Eosinophilic esophagitis.
• Candidiasis.
• CMV esophagitis.

Indications

• Pyrosis = heartburn.

Infection

Main article: Microorganisms

Is a relatively common problem, especially in those that live at the margins (EtOH abusers) and immunosuppressed individuals (HIV/AIDS).

Useful stains

• PAS.
• Gram stain.

Candidiasis

Micro

• Worm-like micro-organisms.

Image: Esophageal candidiasis - wikipedia.org.

Barrett's esophagus

Definition

• Metaplastic transformation of stratified squamous epithelium to simple columnar epithelium with goblet cells.

Microscopy

• Columnar epithelium.
• Goblets cells -- key feature.

Significance

• Increased risk of adenocarcinoma of the esophagus.

Management

• Long term follow-up/repeat esophagogastroduodenoscopy.

Dysplasia

Classification

• Low grade.
• High grade.

Microscopy

• Nuclear changes.
  • Nuclear hyperchromatism.
  • Nuclear crowding.
  • Cigar-shaped (ellipical) nuclei.
• Nuclear changes present at surface (not only in gland crypts).
  • If changes are present at the base but not at the luminal surface -- it "matures" and is not dysplasic.

Notes:

• Changes similar to those see in colorectal tubular adenomas.
• Presence of goblet cells is mildly reassuring its not dysplasia.

Management

Low grade dysplasia.

• Follow-up.

High grade dysplasia.

• Endoscopic mucosal resection.
• Surgical resection ???

Eosinophilic esophagitis

Clinical:

• Dyspepsia.
  • Often mimics gastroesophageal reflux (GERD).
• Dysphagia.

Associations:

• Atopy.
• Celiac disease.
• Oral antigens, i.e. particular foods.
• Familial association.

Microscopy

Features:

• Mucosa with abundant eosinophils: > 20/HPF.
• Basal cell hyperplasia.
• Papillae elongated.

Treatment

• Avoid exacerbating antigens.
• Topical corticosteroids, e.g. fluticasone.

Cancer

General

• Proximal esophagus: squamous cell carcinoma.
• Distal esophagus: adenocarcinoma arising from Barrett's esophagus.

Risks:

• EtOH.
• Barrett's esophagus.
• Smoking.

Adenocarcinoma of the esophagus

General

• Often a prognosis poor - as diagnosed in a late stage.
• May be difficult to distinguish from adenocarcinoma of the stomach.

Tx

• Adenocarcinoma in situ (AIS) - may be treated with endoscopic mucosal resection & follow-up.
• Surgery - esophagectomy.

IHC

Adenocarcinoma:

• CK7 +ve, CK20 +ve.

See also

• Stomach.
• Gastrointestinal pathology.