PATHOLOGY OF NON NEOPLASTIC LESIONS OF THE UPPER GASTROINTESTINAL TRACT.

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Clarissa Black
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1 PATHOLOGY OF NON NEOPLASTIC LESIONS OF THE UPPER GASTROINTESTINAL TRACT.

2 OESOPHAGEAL LESIONS

4 OESOPHAGITIS AND OTHER NON NEOPLASTIC DISORDERS Corrosive Gastroesophageal reflux (GERD), Pills, Acid intake, Irradiation. Infections like Candida, Herpes simplex, CMV, Tuberculosis. Eosinophilic oesophagitis. Barrett Oesophagus. Achalasia Cardia

5 GERD

>2/3 Vascular congestion of papilla Intercellular spaces

6 GERD Histology in NERD on endoscopy Epithelial hyperplasia Basal hyperplasia >15% Papillary elongation.>2/3 Vascular congestion of papilla Intercellular spaces Intraepithelial eosinophils Neutrophils on endoscopy in GERD Ulceration- Severe - on endoscopy in GERD

8 GERD

9 TB Oesophagus

10 Candida

11 Herpes Oesophagitis

12 CMV Oesophagitis.

13 Eosinophilic oesophagitis Endoscopy ringed Oeso, Furrows, narrow Oeso,Strictures or normal. Mostly Males. Eosinophils in epithelium with microabscess.

14 Barrett Oesophagus - A Premalignant condition A change in the Oesophageal epithelium of any length recognised by endoscopy and confirmed to have intestinal metaplasia in the form of Goblet cells by biopsy

15 BARRETT OESOPHAGUS

16 Differential Diagnosis of Oesophageal Glandular epithelium Inadvertently sampled Gastric mucosa or wrongly labeled bottle. GE junction mucosa located in distal 2cms difficult to judge precise location on endoscopy. Hence incidental Goblet cells do not fulfill the criteria. Important as intestinal metaplasia of the cardia is less likely to progress to carcinoma. Hetrotropic Gastric fundic or cardiac mucosa usually in upper Oesophagus. Infants embryonal remnant Rarely ectopic sebeceous glands

17 Barrett Oesophagus with Dysplasia

18 Dysplasia surveillance -4 quadrant biopsies every 2cms Male patients Endoscopically Abnormal erosion, nodule polyp Endoscopically normal

19 Barret oesophagus with severe dysplasia progressing to Carcinoma

20 Achalasia cardia with T cell reaction around Myenteric plexus

21 NON NEOPLASTIC LESIONS OF THE STOMACH

23 Inflammatory lesions of the stomach Acute haemorrhagic /erosive gastritis. Helicobacter gastritis Atrophic gastritis Autoimmune gastritis. Granulomatous gastritis. Eosinophilic gastritis Lymphocytic gastritis Radiation gastritis Gastritis in immunosupressed individuals Gastritis in patients IBD. Gastritis secondary to drug intake

24 Acute and hemorrhagic erosive gastritis Alcohol, Asprins, NSAID,Shock, Sepsis suppurative gastritis

25 PATHOLOGY OF CHRONIC GASTRITIS AND PEPTIC ULCERATION WITH CO-RELATION TO HELICO BACTER INFECTION AND OTHER CAUSES

28 Modified Sydney system of chronic gastritis based on Topography, morphology and etiology

30 Type of Gastritis Etiology Synonyms Non Atrophic Helico bacter Type B: Superficial: Diffuse antral: Chronic Superficial: Interstitial Follicular: Atrophic - Autoimmune Auto immune reaction Type A : Perniceous anemia associated Atrophic Multofocal atrophic Helico bacter, Dietary, Environmental Type B: Special - Chemical Chemicals, Bile, drugs NSAID Type C Special -Radiation Radiation injury Special Lymphocytic Helicobacter : Gluten Special - Granuloma Crohn s, TB, Sarcoidosis, FB Eosinophilic Allergy Celiac associated

Gastritis Chronic Superficial Gastritis with Lymphoid

31 Non Atrophic Helicobacter induced Chronic Gastritis Chronic Active Superficial gastritis Chronic Superficial Gastritis Chronic Superficial Gastritis with Lymphoid hyperplasia 1 to 3 grades Chronic multifocal atrophic gastritis

32 Neutrophils in chronic active gastritis

33 Chronic superficial gastritis with grade 3 lymphoid infiltrates

40 Helicobacter Heilmannii

41 Lymphocytic Gastritis

42 Granulomatous gastritis

43 Eosinophilic gastritis

44 AUTOIMMUNE GASTRITIS Patchy to diffuse Lymphoplasmacytic infiltrate, often in deeper layers. Focal Lymphocytic infiltrate with destruction of gland base Patchy atrophy of mucosa with intestinal/pyloric metaplasia. Parietal cell pseudo hypertrophy. ECL hyperplasia usually linear Negative staining for Gastrin and positive for Chromogranin.

47 Serum antibodies in AG Anti parietal antibodies. 60% of patients Intrinsic factor antibodies in 50% Cross reacting anti canalicularantibody

48 Relation ship between Autoimmune gastritis and Helico Bacter infection Many patients of Helicobacter infection develop autoantibodies like Anticanalicular Antibody Antifoveolar Antibody Antiparietal Antibody. Hence when H.Pylori are present either with AG or suspicious AG, treatment of H. Pylori is important. Result 1. Serum Gastrin levels reduce 2. Regression of ECL Hyperplasia 3. Atrophy persists.

49 Crohn s associated Gastritis

50 Mucor in gastric ca

51 cmv

52 Apergillosois

53 Duodenal biopsy At least 3 sites to be biopsied so that patchy atrophy is not missed. At least one bit should be from Distal Duodenum as pathology is more likely to start in distal end and not in the bulb. Biopsy should be sent for pathology with proper orientation on paper. ie Luminal side uppermost on filter paper

hyper and hypo plasia Surface enterocytes Brush border IEL

54 Histology Architecture of the mucosa with shape of villous thin,leaf like, broad, blunt,flat Villous/ crypt ratio-vc ratio -3:1 to 5:1 Crypt hyper and hypo plasia Surface enterocytes Brush border IEL intraepithelial lymphocytes Gastric metaplasia Presence of Giardia, CMV, Cryptococcus Neoplasia

56 Classification of Duodenal biopsy in relation to malabsorption syndrome A. Severe diffuse villous atrophy Eg. Celiac sprue, Protein allergies, Lymphocytic enterocolitis B. Partial atrophy 1. Hypoplasia- eg Kwashiorkar disease, Megaloblastic anemia, Radiation damage. 2. Without hypoplasia eg. Tropical sprue, infections, Drug induced, IBD, T cell enteropathy, Eoisinophilic enteritis, Autoimmune disorders, Tumours

57 CELIAC SPRUE Immunological injury to Enterocytes due to Gluten Wheat (Gliadins ) Rye (Secalins ) Barley ( Hordeins) HLA associated HLA DQ8 Histology. Flat mucosa Lymphocyte and plasma cell infiltrate Intraepithelial lymphoctes mostly T8 Definitive diagnosis only with serological studies: IgA Antiendomysial Antibodies IgA Anti tissue transglutaminase antibodies

64 Giardiasis

66 Thank you

Common Inflammatory Gastrointestinal Disorders: Endoscopic and Pathologic Correlations

Common Inflammatory Gastrointestinal Disorders: Endoscopic and Pathologic Correlations Nicole C. Panarelli, M.D. Attending Pathologist Montefiore Medical Center Associate Professor of Pathology - Albert