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.[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.
Overview
- Candida - worms.
- HPV - koilocytes.
- CMV - large nuclei.
- HIV - non-specific.
Candidiasis
Gross (endoscopic)
Features:
- White patches.
Microscopic
Features:
- Worm-like micro-organisms.
- Pseudohyphae (single cells).
- Thickness ~ 1/3-1/2 of squamous cell nucleus.
- Should be within (squamous) epithelium.
- On top of epithelium does not count,[2] i.e. it is likely an artifact.
Image: Esophageal candidiasis (WC).
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Cytomegalovirus esophagitis
- AKA CMV esophagitis.
Clinical:
- Classically at the base of the ulcer; within endothelial cells.
Herpes esophagitis
General
Etiology:
- Herpes simplex virus.
Microscopic
Features (3 Ms):
- Moulding.
- Multinucleation.
- Margination of chromatin.
Images:
Human papilloma virus esophagitis
General:
- AKA HPV esophagitis.
Microscopic
Features:
- Koilocytes:
- Perinuclear clearing.
- Nuclear changes.
- Size similar (or larger) to those in the basal layer of the epithelium.
- Nuclear enlargement should be evident on low power, i.e. 25x. [7]
- Central location - nucleus should be smack in the middle of the cell.
Images:
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).[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 ???
Gastroesophageal reflux disease
General
- Abbreviated GERD and GORD (gastro-oesophageal reflux disease).
Clinical:
- Treated with proton pump inhibitors (PPIs).
Microscopic
Features:
- Basal cell hyperplasia.[6]
- Papillae elongation.
- Inflammation, esp. eosinophils, lymphocytes with convoluted nuclei ("squiggle cells").
- +/-Spongiosis.
Notes:
- Eosinophilic esophagitis is characterized by similar histomorphologic features -- key difference: more eosinophils.
Eosinophilic esophagitis
General
Clinical:
Treatment:
- Avoid exacerbating antigens.
- Topical corticosteroids, e.g. fluticasone.
Biopsies:
- Should be taken from: upper, mid, lower and submitted in separate containers (eosinophilia present through-out-- to differentiate from GERD).
Associations:
Gross/endoscopic
Image: Trachealization - radiograph (nih.gov).
Microscopy
Features:[9]
- 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% of studies actually define an area (most studies, embarassing, only give the number of eosinophils per "HPF")![13]
- The group that published the article cited above did another one... [14]
- The Foundation Series book[9] says: "> 20/HPF"; VL sees this definition as garbage, as "HPF" is not defined (see rant in the basics article).
- The most commonly reported cut points are 15, 20 and 24 eosinophils/HPF, without defining HPF.[13]
- 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.[15]
Erosive esophagitis
DDx
- Infections.
- Crohn's disease.
- Pill esophagitis.
Work-up
- GMS.
- PAS.
- IHC for HSV, CMV.
Pill esophagitis
Classic causes:
- Alendronate (Fosamax) - for osteoporosis.
- Iron (can be demonstrated with Prussian blue stain).
- Doxycycline.
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.[5]
- Surgery - esophagectomy.
IHC
Adenocarcinoma:
- CK7 +ve, CK20 +ve.
Weird stuff
- Inflammatory polyp.
- Giant fibrovascular polyp.
- Granular cell tumour.
- Squamous papilloma.
- Heterotopic gastric mucosa ("inlet patch").
See also
References
- ↑ URL: http://dictionary.reference.com/browse/pyrosis. Accessed on: 21 June 2010.
- ↑ ALS. 4 October 2010.
- ↑ GAG Jan 2009
- ↑ GAG Jan 2009
- ↑ 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.
- ↑ Steiner, SJ.; Kernek, KM.; Fitzgerald, JF. (May 2006). "Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis.". J Pediatr Gastroenterol Nutr 42 (5): 506-9. doi:10.1097/01.mpg.0000221906.06899.1b. PMID 16707971.
- ↑ 7.0 7.1 7.2 PMID 19596009.
- ↑ URL: http://www.medicinenet.com/eosinophilic_esophagitis/page2.htm#tocc. Accessed on: 1 December 2009.
- ↑ 9.0 9.1 9.2 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.
- ↑ 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.
- ↑ Al-Hussaini, AA.; Semaan, T.; El Hag, IA.. "Esophageal trachealization: a feature of eosinophilic esophagitis.". Saudi J Gastroenterol 15 (3): 193-5. doi:10.4103/1319-3767.54747. PMID 19636182.
- ↑ URL: http://www.ajronline.org/cgi/reprint/164/4/900.pdf. Accessed on: 4 October 2010.
- ↑ 13.0 13.1 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.
- ↑ PMID 19830560.
- ↑ Liacouras CA, Spergel JM, Ruchelli E, et al. (December 2005). "Eosinophilic esophagitis: a 10-year experience in 381 children". Clin. Gastroenterol. Hepatol. 3 (12): 1198–206. PMID 16361045.