lect.3.diseases of esophagus
DESCRIPTION
diseases of esophagusTRANSCRIPT
Esophagus Secretes mucous, transports food – no enzymes produced,
no absorption Mucosa – protection against wear and tear lamina propria Submucosa Muscularis divided in thirds
Superior 1/3 skeletal muscle Middle 1/3 skeletal and smooth muscle Inferior 1/3 smooth muscle 2 sphincters – upper esophageal sphincter (UES) regulates
movement into esophagus, lower esophageal sphincter (LES) regulates movement into stomach
Adventitia – no serosa – attaches to surroundings < 3 cm below diaphragm
04/11/2023 copyright (your organization) 2003 4
Esophagus Lesions of the esophagus run from bland esophagitis to highly lethal cancers.
All produce dysphagia (difficulty in swallowing), which is attributed either to deranged esophageal motor function or to narrowing or obstruction of the lumen.
Heartburn or Gastroesophageal reflux disease (GERD) (retrosternal burning pain) usually reflects regurgitation of gastric contents into the lower esophagus.
Less commonly, hematemesis (vomiting of blood) and melena (blood in the stools) are evidence of severe inflammation, ulceration, or laceration of the esophageal mucosa.
• Massive hematemesis may reflect life-threatening rupture of esophageal varices.
esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus
Patho----- Of-------Eso
Structural abnormalities of the esophagus can be either congenital or acquired.
The two most common congenital esophageal abnormalities are
Esophageal Atresia (EA) and
Tracheoesophageal Fistula (TEF).
Anatomic disorders encountered infrequently (Table).
Selected Anatomic Disorders Of The Esophagus
Disorder Clinical Presentation and Anatomy
Stenosis Adult with progressive dysphagia to solids and eventually to all foods; a lower esophageal narrowing, which is usually the result of chronic inflammatory disease, including gastroesophageal reflux
Atresia, fistula
Newborn with aspiration, paroxysmal suffocation, pneumonia; esophageal atresia (absence of a lumen) and tracheoesophageal fistula may occur together
Webs, rings Episodic dysphagia to solid foods; a (presumably) acquired mucosal web or mucosal and submucosal concentric ring partially occluding the esophagus
Diverticula Episodic food regurgitation especially nocturnal, sometimes pain is present; an acquired outpouching of the esophageal wall
ANATOMIC AND MOTOR DISORDERS
• Both esophageal anatomy and function may be affected secondarily by many esophageal disorders.
• In hiatal hernia, separation of the diaphragmatic crura and widening of the space between the muscular crura and the esophageal wall permits a dilated segment of the stomach to protrude above the diaphragm.
Two anatomic patterns are recognized: the axial, or sliding hernia and the nonaxial, or paraesophageal hernia.
The sliding hernia constitutes 95% of cases; protrusion of the stomach above the diaphragm creates a bell-shaped dilation, bounded below by the diaphragmatic narrowing.
In paraesophageal hernias, a separate portion of the stomach, usually along the greater curvature, enters the thorax through the widened foramen.
Comparison of the two forms of esophageal hiatal hernias
Only about 9% of these adults, however, suffer from heartburn or regurgitation of gastric juices into the mouth.
Other complications affecting both types of hiatal hernias include mucosal ulceration, bleeding, and even perforation.
Achalasia The term achalasia means "failure to relax" and in the present context denotes incomplete relaxation of the lower esophageal sphincter in response to swallowing.
• Three major abnormalities in
achalasia:
Achalasia
(1) Aperistalsis (absence of peristalsis )(2) partial or incomplete relaxation of the lower esophageal
sphincter with swallowing(3) increased resting tone of the lower esophageal sphincter.
Causes
Primary: achalasia there is loss of intrinsic inhibitory innervation of the lower esophageal sphincter and smooth muscle.
Secondary: achalasia may arise from pathologic processes; example is Chagas disease, caused by Trypanosoma cruzi, which causes destruction of the myenteric plexus of the esophagus, duodenum, colon, and ureter.
Morphology
In primary achalasia there is progressive dilation of the esophagus above the level of the lower esophageal sphincter.
The wall of the esophagus may be normal thickness, thicker than normal because of hypertrophy of the muscularis, or markedly thinned by dilation.
Symptoms• Backflow (regurgitation) of food• Nocturnal regurgitation and aspiration of undigested
food• dysphagia• Chest pain, which may increase after eating or may be felt
in the back, neck, and arms• Cough• Difficulty swallowing liquids and solids• Heartburn • Unintentional weight loss Examination • Esophageal manometry: is a test used to measure the function of the
lower esophageal sphincte by specific tube through esogh to stomach• Esophagogastroduodenoscopy • Upper GI x-ray
Treatment
• Incurable• Palliative measures
– Nonsurgical– Surgical– Both are directed toward relieving the
obstruction caused by the no relaxing LES( lower esogh)
– Injection with botulinum toxin (Botox). This may help relax the sphincter muscles, but any benefit wears off within a matter of weeks or months.
Lacerations (Mallory-Weiss Syndrome)
Longitudinal tears in the esophagus at the esophagogastric junction.
The presumed pathogenesis is inadequate relaxation of the musculature of the lower esophageal sphincter during vomiting.
with stretching and tearing of the esophagogastric junction at the moment of propulsive expulsion of gastric contents.
This thinking is supported by the fact that a hiatal hernia is found in more than 75% of patients with Mallory-Weiss tears.
Tears may involve only the mucosa or may penetrate the wall.
Infection of the defect may lead to an inflammatory ulcer or to mediastinitis [is inflammation of the tissues in the mid-chest].
Esophageal lacerations account for 5% to 10% of upper gastrointestinal bleeding episodes.
Most often bleeding is not profuse and ceases without surgical intervention, but life-threatening hematemesis may occur.
ESOPHAGITIS Injury to the esophageal mucosa with subsequent
inflammation is a common condition worldwide. There are many presumed contributory factors:
Decreased efficacy of esophageal antireflux mechanisms Inadequate or slowed esophageal clearance of refluxed
material The presence of a sliding hiatal hernia Increased gastric volume, contributing to the volume of
refluxed material Impaired reparative capacity of the esophageal mucosa by
prolonged exposure to gastric juices Any one of these influences may assume primacy in an
individual case, but more than one is likely to be involved in most instances.
MORPHOLOGY
• The anatomic changes depend on the causative agent and on the duration and severity of the exposure.
• Mild esophagitis may appear macroscopically as simple hyperemia, with virtually no histologic abnormality.
• Three histologic features are characteristic of uncomplicated reflux esophagitis, although only one or two may be present:
• (1) Eosinophils, with or without neutrophils, in the epithelial layer;
• (2) Basal Zone Hyperplasia;
• (3) Elongation of lamina propria papillae. Intraepithelial neutrophils are markers of more severe injury.
Reflux esophagitis showing the superficial portion of the mucosa. Numerous eosinophils (arrows) are present within the mucosa, and the stratified squamous epithelium has not undergone complete maturation owing to ongoing inflammatory damage.
Clinical Features The dominant manifestation of reflux disease is heartburn,
sour brash. Difficult swallowing (dysphagia), Painful swallowing
(odynophagia) Chest pain, particularly behind the breastbone, that occurs
with eating Swallowed food becoming stuck in the esophagus (food impaction).
Rarely, chronic symptoms are punctuated by attacks of severe chest pain mimicking a heart attack.
The potential consequences of severe reflux esophagitis are bleeding, development of stricture, and Barrett esophagus, with its predisposition to malignancy.
BARRETT ESOPHAGUS Barrett esophagus is a complication of long-standing
gastroesophageal reflux, occurring in up to 10% of patients with persistent symptomatic reflux disease, as well as in some patients with asymptomatic reflux.
Barrett esophagus is defined as the replacement of the normal distal stratified squamous mucosa by metaplastic columnar epithelium containing goblet cells.
Prolonged and recurrent gastroesophageal reflux is thought to produce inflammation and eventually ulceration of the squamous epithelial lining.
Healing occurs by in growth of stem cells and re-epithelialization. In the microenvironment of an abnormally low pH in the distal
esophagus caused by acid reflux, the cells differentiate into columnar epithelium.
MORPHOLOGY Barrett esophagus is apparent as a
salmon-pink, velvety mucosa between the smooth, pale pink esophageal squamous mucosa and the more lush light brown gastric mucosa.
the esophageal squamous epithelium is replaced by metaplastic columnar epithelium (gastric mucosa ).
Critical to the pathologic evaluation of patients with Barrett mucosa is the recognition of dysplastic changes in the mucosa that may be precursors of cancer.
Barrett esophagus. A, Endoscopic view showing red velvety gastrointestinal-type mucosa extending from the gastroesophageal orifice. Note paler squamous esophageal mucosa. B, Microscopic view showing mixed gastric- and intestine-type columnar epithelial cells in glandular mucosa.
Ulcer and stricture may develop as a complication of Barrett esophagus.
Patients with Barrett esophagus have a 30- to 40-fold greater risk of developing esophageal adenocarcinoma compared with normal populations.
30
Gastroesophageal reflux disease (GERD)
Gastroesophageal reflux (GER) is defined as passage of gastric contents into the esophagus.
GER is a normal physiologic process that occurs throughout the day in healthy infants, children, and adults.
Gastroesophageal reflux disease (GERD) occurs when gastric contents reflux into the esophagus or oropharynx and produce symptoms.
DefinitionsGER Passage of gastric contents into
esophagus
GERD Symptoms or complications that may occur when gastric contents reflux into esophagus or oropharynx
Regurgitation Passage of refluxed gastric contents into oral pharynx
Vomiting Expulsion of refluxed gastric contents from mouth
32
Causes Its mostly happen becz the weakness of the lower
esophageal sphincter, or LES Alcohol (possibly) Hiatal hernia Obesity Pregnancy Scleroderma (autoimmune disorder, ) Smoking Some types of food :drinks with caffeine, fatty and
fried foods, garlic and onions, spicy foods
04/11/2023 33
GERD Eosinophilic esophagitisNormal esophagus
The esophageal biopsy specimen shows a small number of intraepithelial eosinophils.
Basal cell thickening of the esophageal mucosal epithelium and lengthening of stromal papillae.
this patient had dysphagia and food allergies that responded to an elimination diet.
04/11/2023 35
Symptoms A burning sensation in your chest (heartburn),
sometimes spreading to the throat, along with a sour taste in your mouth
Chest pain Difficulty swallowing (dysphagia) Hoarseness or sore throat Regurgitation of food or sour liquid (acid reflux) Sensation of a lump in the throat
Respiratory Symptoms of GER
• Apnea/ALTE
• Stridor and hoarseness
• Cough
• Wheezing
• Recurrent pneumonia
DiagnosisEsophagoscopy
To note mucosal changesEsophageal biopsies
To note changes at the cellular levelMotilitiy studies
Low LES pressures are associated with reflux
pH monitoringThe most precise measure for the
presence of acid in the esophageal lumen (24 hour monitoring)
Medical Treatment
Surgical TreatmentIndications for surgical treatment are somewhat
controversialStage 0 and Stage 1 disease should never be an
indication for surgeryStage 2 disease should always undergo a well
supervised period of medical management for at least six months to a year
Stage 3 disease should also undergo medical therapy first
In stage2 and in Stage 3 disease surgical options should be entertained after failed medical management
Surgical Treatment
Nissen fundoplicationTotal or partial
Their aim is to:Restore normal anatomy (intra-abdominal
segment of esophagus)Re-creating an appropriate high-pressure
sound at the esophagogastric junctionMaintaining this repair in the normal
anatomic position
BENIGN TUMORS
Leiomyomas Fibrovascular polyps Condylomas (hpv) Lipomas “Granulation” tissue
(pseudotumor)
ESOPHAGEAL CARCINOMA There are two types: squamous cell carcinomas and
adenocarcinomas . Worldwide, Squamous cell carcinomas constitute 90% of
esophageal cancers. Adenocarcinoma arising in Barrett esophagus is more
common in whites than in blacks. There are striking and puzzling differences in the geographic
incidence of esophageal carcinoma. In the United States, there are about 6 new cases per
100,000 population per year. In regions of Asia extending from the northern provinces of
China to Iran, the prevalence is well over 100 per 100,000.
RISK FACTORS FOR SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS
Esophageal Disorders
Long-standing esophagitis
Achalasia
Plummer-Vinson syndrome (esophageal webs, microcytic hypochromic anemia, atrophic glossitis)
Alcohol consumption
Tobacco abuse
Deficiency of vitamins (A, C, riboflavin, thiamine, pyridoxine)
Deficiency of trace metals (zinc, molybdenum)
Fungal contamination of foodstuffs
High content of nitrites/nitrosamines
Genetic Predisposition
Tylosis (hyperkeratosis of palms and soles)
MORPHOLOGY Squamous cell carcinomas are usually
early overt lesions appear as small, gray-white, plaque like thickenings or elevations of the mucosa and taking one of three forms:
(1) polypoid exophytic masses that protrude into the lumen;
(2) Necrotizing cancerous ulcerations that extend deeply and sometimes erode into the respiratory tree, aorta, or elsewhere
(3) diffuse infiltrative neoplasms that impart thickening and rigidity to the wall and narrowing of the lumen.
Large ulcerated squamous cell carcinoma of the esophagus
Exophytic growing outward
The epithelial lining above is clearly abnormal compared to the normal single-layer ciliated epithelium below.
There is nuclear stratification, nuclear enlargement, hyperchromasia, pleomorphism, and mitoses.
The photomicrograph above shows pseudoinvasion but the same architectural and cytological features.
Micrograph of an esophageal adenocarcinoma (dark blue - upper-left of image) and normal squamous epithelium (upper-right of image). H&E stain.
(a) Histology of squamous cell carcinoma Keratinization is seen.
(b) The tumor cells shows characteristic morphologies of small cell carcinoma.
(c) Tubular formations are seen.
(d) Transitional zone between squamous cell carcinoma element and small cell carcinoma element of the esophageal carcinoma.
Microscopic Image of Esophageal Squamous Cell Carcinoma Microscopic image of Squamous
Papilloma of the Esophagus
51
Adenocarcinomas appear to arise from dysplastic mucosa in the setting of Barrett esophagus.
Unlike squamous cell carcinomas, they are usually in the distal one third of the esophagus and may invade the subjacent gastric cardia.
Microscopically, most tumors are mucin-producing glandular tumors exhibiting intestinal-type features, in keeping with the morphology of the preexisting metaplastic mucosa.
The occasional development of tumors of other alimentary cell types supports the concept that Barrett epithelium arises from multipotential cells.
ADENOCARCINOMA
Clinical Features
Esophageal carcinoma is insidious in onset and produces dysphagia and obstruction gradually and late.
Weight loss, anorexia, fatigue, and weakness appear, followed by pain, usually related to swallowing.
Because these cancers extensively invade the rich esophageal lymphatic network and adjacent structures, surgical excision rarely is curative.
Diagnosis is usually made by imaging techniques and endoscopic biopsy.
Esophagogastroduod enoscopy
Diagnosis
QUIZ