Esophagus

From Libre Pathology
Revision as of 04:07, 2 July 2010 by Michael (talk | contribs) (→‎Eosinophilic esophagitis: HPF -- definition)
Jump to navigation Jump to search

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

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

Microscopic:

  • Worm-like micro-organisms.

Image: Esophageal candidiasis (WC).

Barrett's esophagus

Definition

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

Microscopic

Features:

  • 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

Features:

  • Nuclear changes.
    • Nuclear hyperchromatism.
    • Nuclear crowding.
    • Cigar-shaped (ellipical) nuclei.
  • Nuclear changes present at surface (not only in gland crypts).[2]
    • 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.[3]

Management

Low grade dysplasia.

  • Follow-up.

High grade dysplasia.

  • Endoscopic mucosal resection.[4]
  • Surgical resection ???

Eosinophilic esophagitis

General

Clinical:

  • Dyspepsia.
    • Often mimics gastroesophageal reflux (GERD).[5]
  • Dysphagia.[6]

Associations:

  • Atopy.[7]
  • Celiac disease.[8]
  • Oral antigens, i.e. particular foods.[5]
  • Familial association.[5]

Microscopy

Features:[7]

  • Mucosa with "abundant eosinophils".
  • Basal cell hyperplasia.
  • Papillae elongated.

Notes:

  • Criteria for number of eosinophils/area is highly variable; there is a 23X fold variation in published values and only 11% actually define an area![9]
  • The Foundation Series book[7] says: "> 20/HPF"); VL sees this definition as garbage, as "HPF" is not defined (see rant in the basics article).
  • Another paper says "> 15/HPF".[10]

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.[4]
  • Surgery - esophagectomy.

IHC

Adenocarcinoma:

  • CK7 +ve, CK20 +ve.

See also

References

  1. URL: http://dictionary.reference.com/browse/pyrosis. Accessed on: 21 June 2010.
  2. GAG Jan 2009
  3. GAG Jan 2009
  4. 4.0 4.1 Sampliner RE (March 2009). "Endoscopic Therapy for Barrett's Esophagus". Clin. Gastroenterol. Hepatol.. doi:10.1016/j.cgh.2009.03.011. PMID 19306943.
  5. 5.0 5.1 5.2 PMID 19596009.
  6. URL: http://www.medicinenet.com/eosinophilic_esophagitis/page2.htm#tocc. Accessed on: 1 December 2009.
  7. 7.0 7.1 7.2 Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 19. ISBN 978-0443066573.
  8. Leslie C, Mews C, Charles A, Ravikumara M (April 2010). "Celiac disease and eosinophilic esophagitis: a true association". J. Pediatr. Gastroenterol. Nutr. 50 (4): 397–9. doi:10.1097/MPG.0b013e3181a70af4. PMID 19841598.
  9. Dellon ES, Aderoju A, Woosley JT, Sandler RS, Shaheen NJ (October 2007). "Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review". Am. J. Gastroenterol. 102 (10): 2300–13. doi:10.1111/j.1572-0241.2007.01396.x. PMID 17617209.
  10. Liacouras CA (December 2008). "Eosinophilic esophagitis". Gastroenterol. Clin. North Am. 37 (4): 989–98, xi. doi:10.1016/j.gtc.2008.09.004. PMID 19028328.