Esophagus

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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.

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.[1]

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.[2]

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).[3]
    • 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.[4]

Management

Low grade dysplasia.

  • Follow-up.

High grade dysplasia.

  • Endoscopic mucosal resection.[5]
  • Surgical resection ???

Eosinophilic esophagitis

Clinical:

  • Dyspepsia.
    • Often mimics gastroesophageal reflux (GERD).[6]
  • Dysphagia.[7]

Associations:

  • Atopy.[8]
  • Celiac disease.[9]
  • Oral antigens, i.e. particular foods.[6]
  • Familial association.[6]

Microscopy

Features:[10]

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

Treatment

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

Cancer

General

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.[5]
  • Surgery - esophagectomy.

IHC

Adenocarcinoma:

  • CK7+, CK20+

See also

References

  1. ↑ http://dictionary.reference.com/browse/pyrosis
  2. ↑ NEED REF.
  3. ↑ GAG Jan 2009
  4. ↑ GAG Jan 2009
  5. ↑ 5.0 5.1 Sampliner RE (March 2009). "Endoscopic Therapy for Barrett's Esophagus". Clin. Gastroenterol. Hepatol.. doi:10.1016/j.cgh.2009.03.011. PMID 19306943.
  6. ↑ 6.0 6.1 6.2 PMID 19596009.
  7. ↑ URL: http://www.medicinenet.com/eosinophilic_esophagitis/page2.htm#tocc. Accessed on: 1 December 2009.
  8. ↑ GLP P.19.
  9. ↑ PMID 19841598.
  10. ↑ GLP P.19.
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