Pathology of Esophagus PDF

Pathology of esophagus BY DR. HUSAMELDIN OMER  Esophageal anomalies Congenital malformations of the esophagus are known pediatric disorders. They consist of congenital esophageal stenosis, esophageal atresia with or without tracheoesophageal fistula, laryngotracheoesophageal...

Pathology of esophagus BY DR. HUSAMELDIN OMER  Esophageal anomalies Congenital malformations of the esophagus are known pediatric disorders. They consist of congenital esophageal stenosis, esophageal atresia with or without tracheoesophageal fistula, laryngotracheoesophageal cleft and esophageal duplication cyst Congenital esophageal stenosis (CES) is a rare anomaly, resulting from incomplete separation of the respiratory tract from the primitive foregut. Historically it has been confused with esophageal strictures secondary to inflammation, that occurs mainly due to gastroesophageal reflux. First clinical sings are abnormalities of the swallowing mechanism Esophageal atresia; A malformation in which the esophagus has two separate sections—upper and lower— that do not connect. A baby with this condition is unable to pass food from the mouth to the stomach and also may have difficulty breathing. May be incompatible with life and it sometimes associated with congenital heart diseases. There are five types of esophageal atresia: Type A The upper and lower parts of the esophagus do not connect and have closed ends. In this type, no parts of the esophagus attach to the trachea. Type B is very rare. In this type, the upper part of the esophagus is attached to the trachea (forming fistula). The lower part of the esophagus has a closed end. Type C is the most common type. In this type, the upper part of the esophagus has a closed end. The lower part of the esophagus is attached to the trachea. Type D is the rarest and most severe. In this type, each of the upper and lower parts of the esophagus are connected separately to the trachea (two fistulae). Esophageal atresia & fistulae A laryngo-tracheo-esophageal cleft (LC) is a congenital malformation characterized by an abnormal, posterior, sagittal communication between the larynx and the pharynx, possibly extending downward between the trachea and the esophagus. Esophageal duplication cysts are rare congenital malformations which are typically located in the right postero-inferior mediastinum. Esophageal duplications are the second cause of posterior mediastinal mass in children, after neuronal tumors. The most common presenting symptoms are respiratory distress and strider secondary to airways compression, and dysphagia.  Acquired non inflammatory disorders of the esophagus These include Esophageal achalasia:, hiatal hernia, E diverticula, E varices, E webs and rings Esophageal achalasia: a rare disorder in which the esophagus is unable to move food and liquids down into the stomach due to failure of relaxation of the lower esophageal sphincter. The etiology is not fully known in most cases. However, it is thought to occur from the degeneration of the myenteric plexus and vagus nerve fibers of the lower esophageal sphincter. In South America: chagas disease (trypanosomiasis) may destruct the myenteric plexus leading to achalasia The majority of patients with achalasia typically present with dysphagia. Achalasia occurs with equal frequency in both males and females. The peak incidence between the ages of 30 to 60 years. However, less than 2% to 5% of cases occur in children less than age 16 years. Histopathological findings in advanced achalasia treated with total thoracic esophagectomy show a significant reduction in the number of myenteric ganglion cells and complete absence in some patients. Hiatal (hiatus) hernia Upward protrusion of a part of the stomach through the diaphragm into the chest cavity. Occurs in 1-20% of adult subjects. Two types are found: A) Sliding H hernia (95% of cases). stomach slides up through the widened hiatus at times and then slides back down. B) Paraesophageal H hernia. This is a very common condition, especially old people. It may not cause symptoms, but when it does, they're usually related to acid reflux. About (9%) of the patients suffer from heartburn. Complications: ulcerations, bleeding and even perforation  Types of hiatal hernias A) Sliding (rolling) H hernia B) Paraesophageal H hernia Esophageal diverticula: A relatively rare acquired disorder in which a partial out- pouching of the esophageal wall occurs. There are two main types: Pulsion diverticulum is created when there is increased intraluminal pressure causing herniation of the esophageal wall in an area of weakness and usually occur in the setting of dysmotility of the esophagus. This occurs when there is an inadequate relaxation of either the upper (pharyngeal Zenker diverticula) or lower esophageal sphincter (Epiphrenic diverticula). Traction diverticulum occurs when there is an external force on the esophageal wall such as mediastinal inflammation (e.g. TB) that adheres and pulls on the esophageal wall. This mid- esophageal diverticulum (Rokitansky diverticulum.) is usually true diverticulum. True diverticula are outpouchings that include all layers of the esophageal wall while false diverticula only include the mucosa or submucosa. Esophageal diverticula cause episodic food regurgitation especially nocturnal, and this accompanied sometimes with pain. Dysphagia is also a known feature. Esophageal varices: Dilated sub-mucosal veins in the lower third of esophagus.  Causes: Portal hypertension and liver cirrhosis  Clinical manifestations: 50% of cases suffer massive hematemesis. 20-30% of cases die during the first episode.  Esophageal varices (A). Two varices were found at 9 o’clock and 6 o’clock (B). The varices found obviously at 2 o’clock. Esophageal webs and rings  Mucosal webs: are acquired smooth ledges of mucosa, usually occurs in upper esophagus.  Rings: concentric tissue rings protruding usually into the distal esophageal lumen. Both may cause episodic (accidental) dysphagia to solid foods (but not liquid) and nocturnal regurgitation. There is a risk of esophageal carcinoma in 5% of cases Esophageal webs & rings  Esophagitis Predisposing conditions:  Reflux of gastric contents (reflux esophagitis), the most common cause in western countries.  Ingestion of irritants as: alcohol (chronic alcoholism), corrosive acids or alkalis, excessive hot fluids, smoking.  Bacterial, viral, or fungal infections.  Radiation.  Some drugs as vibramycin, tetracycline, Bactrim, brufen, Naprosyn, ferrous sulfate, theophylline and others. Reflux esophagitis: Pathogenesis: Gastric regurgitation leads to exposure of esophageal mucosa to gastric contents and this causes mucosal damage and inflammation. Clinical manifestations: Heartburn, Regurgitation and Hematemesis or melena. Gross appearance (endoscopy): Hyperemia, edema, Superficial necrosis and ulceration. esophagitis, microscopic  Thickening of the basal layer.  Thinning of the superficial layer.  Infiltration of the tissue by eosinophils, PNLs, and chronic inflammatory cells including the epithelial layer. Barrett’s esophagus: Metaplasia of the distal esophageal squamous epithelium to columnar epithelium, in response to prolonged irritation that mainly due to chronic esophageal reflux Most common in adults. Clinical importance: Dysplasia may occur. There is a considered risk of development ofesophageal adenocarcinoma ( 30-40 higher fold). Barrett’s esophagus  Esophageal endoscopy showing red velvety mucosa (metaplastic).  Intermitted with paler normal mucosa. Barrett’s esophagus, microscopic  On the right side normal squamous cell covering.  On the left side metaplastic cells containing mixture of gastric and intestinal epithelium  Esophageal tumors  Benigntumors: classification Esophageal Malignant Squamous cell papilloma Squamous cell carcinoma (common) Fibrovascular polyp Adenocarcinoma Leiomyoma Stromal sarcomas (rare) Fibroma Lipoma Hemangioma Neurofibroma Lymphangioma Squamous cell carcinoma of esophagus:  The most common type of esophageal cancer.  Occurs in adults over 50 years.  Males are affected more than females (3:1).  Pathogenesis: multifactorial  Chronic esophagitis.  Heavy smoking,  Alcohol abuse.  Plummer-Vinson syndrome (webs, anemia, and atrophic glossitis)  Achalasia. Gross appearance:  Sites: middle 3rd (50%), lower 3rd (30%) upper 3rd (20%).  Types: it may be polypoid (60%), ulcerative (25%), or infiltrative (15%). Microscopic:  Well differentiated squamous cell carcinoma, (90%).  Poorly differentiated squamous cell carcinoma. Esophageal squamous carcinoma  Esophageal endoscopy showing an ulcer (arrow) with raised everted edge and necrotic floor.  Esophageal squamous carcinoma  Microscopic examination revealed well differentiated squamous cell carcinoma with cell nests (white arrow). Clinical manifestations:  Progressive dysphagia.  Weight loss.  Anorexia.  Pain related to swallowing.  Hemorrhage. Prognosis:  5-year survival is 75% in superficial type. Adenocarcinoma of esophagus:  Constitutes about 25% of cancer esophagus. Pathogenesis: Barrett’s esophagus & epithelial dysplasia are predisposing factors. Gross appearance:  Common in the distal 3rd of esophagus.  Polypoid nodule, ulcerative, or infiltrative. Microscopic:  Mucin producing malignant columnar cells with intestinal features, or signet-ring cell pattern.  Esophageal adenocarcinoma, microscopic  Glandular structures lined by mucin- producing malignant epithelial cells. Clinical features:  Symptoms are like those of squamous cell carcinoma.  Arise in patients older than 40.  Occurs in males more often than females. Prognosis:  5-year survival is less than 20%.