Lesions of the oral cavity Salivary glands. See Oral pathology

Transcription

1 Lesions of the oral cavity Salivary glands See Oral pathology

2 Esophagus From highly lethal Ca to bland esophagitis. Dysphagia, heartburn, hematemesis, melena. Anatomic and motor disorders: Stenosis - adults, dysphagia, lower esophagus narrowing due to reflux and inflammation Atresia and fistula - newborn with aspiration (absence of lumen), tracheoesophageal fistula (may be together) Mucosal webs - acquired mucosal membrane occluding the lumen Diverticula - nocturnal regurgitation, acquired outpouching of the wall

3 Esophagus Hiatal hernia: Separation of the diaphragmatic crura and widening of the space between the muscular crura. Two patterns: 1/axial (sliding) hernia - 95 % of cases, protrusion of stomach through the diaphragm, bell-shaped, 2/paraesophageal (rolling) - separate portion of stomach, cause obscure. Heartburn, regurgitation of food, incompetence of sphincter. Obesity! Complications - ulceration, bleeding, perforation.

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5 Esophagus Achalasia: "Failure to relax" of lower esophageal sphincter in swallowing aperistalsis, partial or incomplete relaxation of the lower sphincter, increased resting tone of the lower sphincter Impaired arrangement of innervation. Secondary - destruction of the myenteric plexus Chagas' disease (Trypanosoma cruzi). Progressive dilatation of proximal esophagus, inflammation, thickening, nocturnal regurgitation, young adults, childhood, risk of squamous Ca.

6 Esophagus Laceration (Mallory-Weiss syndrome): Longitudinal tears - chronic alcoholics inadequate relaxation of the musculature of lower sphincter during vomiting. Mucosal tear - bleeding, wall tear - ulcer, mediastinitis

7 Esophagus Varices: Porto-caval anastomoses Liver cirrhosis - portal hypertension 2/3 of all cirrhotic patients massive hemorrhage, 40% die during first episode, 1/2 within 1Y

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11 Esophagus Esophagitis: gastric intubation, uremia, irritant foods, alcohol, smoking, radiation, chemotherapy Higher incidence in Northern Iran and China Mild - hyperemia, severe - ulceration Heartburn, regurgitation, chest pain (mimicking MI), bleeding, Barrett

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15 Esophagus Barrett's esophagus: long-lasting reflux, abnormal metaplastic columnar epithelium with goblet cells low ph - ulcers, 30-40x increased risk of adenoca. red, velvety mucosa - up from gastroesophageal junction or isolated islands in the distal esophagus

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21 Esophageal tumors Benign tumors papilloma Leiomyoma Lipoma Etc.

22 Esophageal carcinoma squamous cell Ca Risk factors:» esophagitis, achalasia, PlummerVinson sy (microcytic hypochromic anemia, atrophic glossitis)» Life style - alcohol, tobacco» Genetic - tylosis (hyperkeratosis of palms and soles) - Northern Iran» Barrett - adenoca» Long prodromes, dysplastic changes.

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24 Esophageal carcinoma Grossly: 1/polypoid 2/ulcerative 3/diffuse AdenoCa: Barrett - distal esophagus Weight loss, anorexia, fatigue, pain related to swallowing Biopsy, surgery

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35 Stomach From bland gastritis to carcinoma. Congenital. pyloric stenosis, diaphragmatic hernia, gastric heterotopia (esophagus, small intestine - Meckel). Heartburn, vague pain, hematemesis, melena. Gastritis: Inflammation of gastric mucosa. Acute or chronic

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37 Chronic gastritis Type B > frequent x acute atrophy or metaplasia Helicobacter pylori, persists for decades enzymes + toxins + noxious chemicals from recruited neutrophils Intestinal metaplasia - dysplasia Proliferation of lymphoid tissue - ML Hypochlorhydria Type A autoimmune - antibodies x parietal cells atrophy - loss of acid + intrinsic factor achlorhydria pernicious anemia hypergastrinemia

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46 Peptic ulcers Erosion mucosa Ulcer lamina muscularis mucosae and deeper Acute or chronic Gastric x duodenal Loss of balance betwen protective and aggressive forces Most frequent cause = Helicobacter p. Helicobacter pylori - > 70% gastric ulcers Only 10-20% patients with Helicobacter pylori develop peptic ulcer. Unknown interactions. Zollinger-Ellison sy - hypergastrinemia Cigarette smoking, alcohol. corticosteroids, stress

47 Acute peptic ulcers Acute ulcers: Mainly in stomach, rare in duodenum stress trauma, surgical injury of CNS, extensive burns, gastric irritant drugs Small - up to 1 cm, anywhere in the stomach, usually multiple. Adjacent mucosa without inflammation

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49 Chronic peptic ulcers Chronic u. - several cm Elevated walls - radial mucosal folds. Gastritis is almost always associated. Complications: penetration - to omentum, liver, pancreas perforation peritonitis bleeding - melena, exsanguination Symptoms - burning and boring pain, weight loss, hemorrhage. Pain is worse at night, relieved by alakali or food

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52 Tumors Epithelial tumors predominate Polyps: 1/ hyperplastic % - not true neoplasms 2/ fundic gland polyps - 10% - dilated glands 3/ adenomatous - 5% - true neoplasms All more frequent in chronic gastritis.

53 Gastric carcinoma AdenoCa (95%), Geographical incidence - most common in Japan, Hungary. AdenoCa - two forms 1/ intestinal type - from intestinal metaplasia - chronic gastritis - male predominance - nitrites, smoked foods, Helicobacter pylori, pernicious anemia 2/ diffuse type - in younger, directly from gastric glands - risk factors unknown

54 Gastric carcinoma Localization- pylorus, antrum, cardia, remainder of the body and fundus Early cancer - mucosa, submucosa Morphology: 1/ exophytic 2/ flat 3/ ulcerative Leather-bottle stomach - scirhous carcinoma (linitis plastica)

55 Gastric carcinoma Histology: 1/ intestinal type 2/ diffuse - "signet ring" cells Metastasis - regional lymph nodes, supraclavicular node (Virchow's). Krukenberg tumor (ovary), liver Symptoms - abdominal discomfort, weight loss, pain. Therapy surgery Prognosis very bad in advanced

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62 Small intestine developmental anomalies Atresia - segmental Stenosis - segmental Duplication Meckel's diverticulum - failure of involution of omphalomesenteric duct, 34 cm long, distal ileum, asymptomatic, gastric metaplasia, islands of pancreatic tissue

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64 Large intestine developmental anomalies Malrotation - cecum in left upper abdomen (confusing appendicitis), Hirschprung disease - megacolon

65 Hirschprung disease - congenital megacolon Aganglionic segment of intestinal wall - 1/5 of cases longer segment, rarely - the whole colon. Males predominate (4:1). Sometimes extreme dilatation (1520 cm in diam.) - ulcers, stercoral peritonitis. resection of aganglionic segment (frozen sections intraoperative). x Acquired megacolon: 1/Chagas's disease - trypanosomes destroy the plexus 2/obstruction by the tumor 3/toxic megacolon 4/functional psychosomatic disorder

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67 Vascular disorders Ischemic bowel disease: Acute occlusion infarction. end-arteries - transmural necrosis venous obstruction (thrombosis) hemorrhagic infarsation.

68 Vascular disorders Conditions 1/ arterial thrombosis - AS, vasculitis, surgical accidents, oral contraceptives 2/ arterial embolism 3/ venous thrombosis 4/ non-occlusive ischemia - shock, dehydration, cardiac failure

69 Vascular disorders Transmural infarction - dark red hemorrhagic, gangrene (bacteria), perforation Mural and mucosal - multifocal, ulcerations, inflammation, pseudomembrane Symptoms - usually in older patients, transmural - severe pain, bloody diarrhea, shock, high mortality Mural and mucosal - abdominal distention, bleeding, pain, may be fatal but may heal

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73 Vascular disorders Angiodysplasia: Tortuous dilatation of mucosal and submucosal vessels - cecum, 6th decade, bleeding hereditary hemorrhagic teleangiectasia (Osler-Weber-Rendu sy) isolated lesions, cause - mechanical factors Hemorrhoids: Varices - rectum and anus, after the age of 50, pregnancy, obstipation, liver cirrhosis Complications - bleeding, prolaps, thrombosis

74 Diarrheal diseases Bacterial enterocolitis: Toxins (Staphylococcus aureus, Vibrio, Clostridium perfringens,, Clostridium botulinum), Salmonella (typhi, enteritidis) - S. typhi - typhoid fever Shigella - distal colon. Campylobacter jejuni - superficial ulcers. Yersinia enterocolitica - lymph node granulomas (lymphadentis mesenterialis). Vibrio cholerae - small intestine, mucus depleted crypts. Clostridium difficile - pseudomembranous colitis. Clostrdium perfringens - severe necritizing enterocolitis with perforation (pigbel)

75 Diarrheal diseases Viral gastroenteritis - (gastritis less pronounced in a case of all gastroenteric cases): Rotavirus, Norwalk virus, other viruses (adenovirus, calcivirus, astrovirus) Protozoal infection: Entamoeba histolytica Giardia lamblia

76 Malabsorption syndromes Impaired absorption of fats, proteins, carbohydrates, electrolytes, minerals, and water Most common - due to pancreatitis, celiac sprue, and Crohn's disease

77 Malabsorption syndromes Pancreatic insufficiency - chronic pancreatitis, cystic fibrosis. Bacterial overgrowth - osmotic diarrhea, steatorrhea Lactose intolerance - inherited disaccharidase deficiency - milk intolerance

78 Malabsorption syndromes Gluten-sensitive enteropathy = celiac sprue non-infectious - crossreactivity sensitivity to gluten (grains of wheat, oat, barley, rye) epithelial damage Tropical sprue - infection (unknown), diffuse enteritis, ATB treatment Whipple's disease - intestine, CNS, joints macrophages laden by Gram+ Tropheryma whippelii ATB treatment, males, 4-5th decade

79 Idiopathic inflammatory bowel disease Crohn's disease Ulcerative colitis

80 Idiopathic inflammatory bowel disease Crohn's disease segmental transmural inflammation, fibrosis and thickening, usually terminal ileum and caecum "skips", anywhere in GIT (systemic disease accompanied by uveitis, sacroilitis, polyarthritis, sclerosing cholangoitis Any age, most 2nd - 3rd decade Symptoms - non-characteristic - pain, fever, diarrhea, sometimes bleeding, remissions, relapses

81 Idiopathic inflammatory bowel disease transmural, mucosal damage, granulomas, fissures and fistulae ulcers in mucosa, mucosal inflammation, granulomas dysplastic changes, higher risk of Ca Complications - fistulae to other bowel loops, urinary bladder, vagina, skin, abdominal abscesses, intestinal strictures

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83 Idiopathic inflammatory bowel disease Ulcerative colitis limited to mucosa and submucosa. Starts in rectum, extends proximally (whole colon) Systemic disease - migratory polyarthritis, uveitis, sclerosing cholangitis Any age, peak years Symptoms - pain, bloody mucosal diarrhea, weight loss Extraintestinal manifestations - migratory polyarthritis Dg - endoscopy, biopsy

84 Idiopathic inflammatory bowel disease Ulcerative colitis Granulomas & skip lesions absent, little fibrosis Rectum+sigmoideum - 80%, entire colon 10%. Bleeding, edema, inflammatory pseudopolyps ulcers - longitudinal, sometimes gangrene, mucosal atrophy Diffuse inflammatory infiltrate, crypt abscesses ulcer healing - submucosal fibrosis Dysplastic changes, high risk of Ca (duration & extent of disease play a role)

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87 Colonic diverticulosis Congenital - all three layers - Meckel. Most - acquired - anywhere in GIT, mostly in sigmoid colon nerves and vessels penetrate internal (circular) muscular layer - defects Older age, Western countries (low fiber diet) Symptoms - asymptomatic, discomfort diverticulitis - pain, abscess formation. Treatment - high-fiber diet, diverticulitis - surgery

88 Colonic diverticulosis Two factors: 1/ peristaltic contractions - elevation of pressure 2/ focal defects of muscular wall Appearance - up to 1 cm, usually sigmoid, adjacent to teniae, thin-walled Complications - inflammation diverticulitis, perforation - peritonitis, adhesions

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90 Bowel obstruction Hernias - protrusion of pouchlike, serosalined sac of peritoneum - hernial sac. Inguinal, femoral, umbilical canal, surgical scars. Retroperitoneal hernia - Treitz ligament. Segments of viscera trapped, Incarceration ischemia necrosis (hemorrhagic infarction), ileus Acute abdomen!

91 Bowel obstruction Intussusception - proximal segment to distal Volvulus - twisting of the loops or other structures (ovary) - small bowel usually - obstruction, infarction

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94 Tumors High incidence of colorectal Ca in Czech Republic Vast majority- large intestine Polyps Sessile Pedunculated non-neoplastic - inflammatory Hyperplastic adenomatous polyps Mesenchymal lymphoid

95 Tumors Non-neoplastic polyps - increase with age, 90% of all polyps, hyperplastic - small (up to 5 mm), singly or multiple, no malignant potential! Juvenile polyps - hamartomatous, cystic glands, children younger than 5 years. In adults - retention polyps - long stalk, occur in rectum Peutz-Jeghers polyps - hamartomatous smooth muscle within mucosal stroma

96 Adenomas Small to large, large intestine, dysplastic changes Majority of all adenoca arise from adenomas Symptoms - asymtomatic, occult bleeding, bleeding, anemia. Polyp in Vater's ampulla biliary obstruction. All adenomas potentially malignant Three types: 1/tubular 2/villous 3/tubulovillous

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100 Adenomas Tubular - most common, pedunculated, branching glands, dysplasia biopsy sometimes intramucosal Ca - invasive growth into the stalk Villous - larger, sessile - up to 10 cm in diam., higher risk Tubulovillous - admixture. Risk of Ca - size, histology, grade of dysplasia

101 Familial polyposis syndromes Autosomal dominant, familial adenomatous polyposis (FAP) Gardner sy - more than 100 Most - tubullar adenomas Risk of Ca - 100% by mid life. Hereditary nonpolyposis colorectal cancer (HNPCC) - autosomal dominant (Lynch's sy) - high risk of colorectal Ca and endometrial Ca

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103 Colorectal carcinoma Large intestine (98%), 6-7th decade Higher risk - adenomas, ulcerative colitis M>F High USA, Europe Low India, South America, Africa. Japan Dietary causes: 1/ low-fiber 2/ high content of refined carbohydrates 3/ high content of animal fat 4/ low vitamin A, C, and E

104 Colorectal carcinoma Distribution of Ca proximal colon - polypoid, fungating mass. Sigmoid&rectum - circular, stenosing Both penetrate up to the serosal surface Symptoms - silent, fatigue, iron deficiency anemia Right sided bleeding Rectal stenosis Meta - regional LN, liver, lungs, bones Detection - occult bleeding test, colonoscopy, biopsy, CT - spread (metastases) Therapy surgery, radiation, chemotherapy

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112 Small intestinal tumors Only 3-6% of GIT tumors AdenoCa - unusual, circular growth duodenum (ampula), LN spread Carcinoid - producing hormones (serotonine) derived from neuroendocrine cells low-grade malignant, local infiltrative growth, meta rare Small bowel, appendix, rectum, bronchi

113 Small intestinal tumors Carcinoid yellow-tan, desmoplasia Mitoses rare Asymptomatic - hormones metabolized in liver Carcionid sy - (cutaneous flushes, diarrhea, asthma, heart fibrosis (pulmonary + tricuspid valve) - hepatic metastases. GIT malignant lymphoma - usually nonhodgkin, MALToma, H. pylori!

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115 Appendix Acute appenicitis - acute abdomen. oxyuris vermicularis Mucocele - dilatation of the lumen by mucus - non-tumorous obstruction (fecalith) - mucosal atrophy rarely mucocele ruptures mucoperitoneum

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117 Appendical tumors Carcinoid Mucinous cystadenoma cystadenoca Pseudomyxoma peritonei = mucus+tumor cells, implantation metastasis Jelly like material in peritoneal cavity