gastrointestinal system part ii the oesophagus. a muscular tube conduction of food and drink...
TRANSCRIPT
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Gastrointestinal system Part II
The oesophagus
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A muscular tube
Conduction of food and drink
Sphincters at top and bottom
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Histology
Non-keratinising squamous epithelium
Submucosa Lamina properia Muscularis mucosa Muscular layer Advanticia No mesothelia coverage
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Congenital and mechanical disorders (1)
Atresia – often with fistula to trachea Hiatus hernia (presence of stomach in
thoracic cavity) – due to increased intra-abdominal pressure
Sliding hernia>95% Paraesophageal<5%
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Hiatal hernia……..
Heart burn&Regurgitation Reflux esophagitis Esophageal ulcer Strangulation
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…Mechanical disorders (2)
Achalasia Failure of relaxation of lower
oesophageal sphincter (destruction or degeneration of nerve plexus)
Similar features in Chagas’ disease (South American trypanosomiasis)
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Achalasia…..
Apristalsism Lack or decreased LES relaxation Esophageal rest hypertonisity Pre stenotic dilatation&muscle
hypertrophy Dysphagia,regorgitation,aspiration SCC 5% in younger patient
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Oesophageal varices
Localised dilatation of lower oesophageal veins
Secondary to portal hypertension (portal vein thrombosis or hepatic cirrhosis)
Haemorrhage can be catastrophic
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Mallory weiss syndrome
Longitudinal tearing in GE junction
Hyperemesis Hematemesis Superficial or
deep
Mediastinitis No sequela
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Inflammation (oesophagitis)
Acute infective – Herpes virus, Candida. Both seen most commonly in immunosuppressed.
Ingestion of corrosives Chronic reflux through lower
oesophageal sphincter(most common) Uremia,chemotherapy,radiation Sliding hiatal hernia
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Herpes oesophagitis
Punched-out ulcers Viral intranuclear inclusions Formation of multinucleated giant cells
(cytopathic effect)
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Herpes oesophagitis
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Candida oesophagitis
Haemorrhagic mucosa with white plaques
Fungal hyphae and yeast forms on microscopy
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Reflux oesophagitis
Common – often without symptoms Mucosa exposed to acid-pepsin and bile Increased cell loss and regenerative activity
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Consequences of reflux oesophagitis
Ulceration Stricture Glandular
metaplasia (Barrett’s oesophagus)
Carcinoma
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Barrett’s oesophagus
Columnar epithelial cells in lower oesophagus
Variable extent Presence of goblet
cells “intestinal metaplasia” associated with risk of progression to dysplasia/cancer 30-40 X
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Oesophageal neoplasms
Benign tumours (rare): squamous papilloma, leiomyoma
Malignant tumours Squamous carcinoma Adenocarcinoma
Presenting symptom - dysphagia
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Epidemiology of oesophageal cancer
Squamous carcinoma commonest worldwide 1-2% all cancer death
Adenocarcinoma has very different risk factors and is now the commonest type in Europe/N.America
Scc >90% in other parts In US 50%
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Squamous carcinoma
High incidence in Southern Africa (incl. Malawi), China, Iran
Probably diet related (A and B vitamin deficiency, fungal contamination) – tobacco and alcohol also risk factors
Associated with chronic non-specific oesophagitis
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Gross morphology
Fungative masses penetrating ulceration Infiltration into the eso.wall
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Squamous carcinoma
Often large exophytic occluding tumours
Invasive disease preceded by dysplasia and carcinoma in situ
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Adenocarcinoma
Occurs in lower oesophagus
Often associated with Barrett’s oesophagus (progresses through dysplasia to cancer)
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Clinical course of oesophageal cancer
Grim! (even with best available resource)
Tumours have commonly spread to regional nodes and/or liver at presentation
No peritoneal lining in mediastinum – local invasion (heart, trachea, aorta) often limits surgery
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Any question?