Gastrointestinal pathology 2018 lecture 2. Dr Heyam Awad FRCPath

Transcription

1 Gastrointestinal pathology 2018 lecture 2 Dr Heyam Awad FRCPath

2 Eosinophilic esophagitis Incidence of eosinophilic gastritis is increasing. Symptoms: food impaction and dysphagia. Histology: infiltration by numerous eosinophils.( at least 25 neutrophils per high power field) The majority of patients are atopic and have other allergic diseases like atopic dermatitis, allergic rhinitis, asthma Treatment: 1. dietary restriction of food allergens like milk and soy products. 2. steroids Note: these patients do not respond to proton pump inhibitors which are used in reflux esophagitis.

3 Eosinophilic esophagitis: we need to see 25 eosinophils per high power field (25/ HPF) to call the disease eosinophilic esophagitis.

4 Barret esophagus It is a complication of gastroesophageal reflux (GERD) = intestinal metaplasia of the esophageal squamous mucosa 10% of people with symptomatic GERD have Barrett esophagus Males are affected more than females Increased risk of esophageal malignancy ( adenocarcinoma) Dysplasia can occur in Barrett (around 1% of cases).

5 morphology Endoscopy: tongues or patches of red mucosa extending upwards from the gastroesophageal junction Note: normal esophageal mucosa appears pale in color. Histology: gastric or intestinal metaplasia ( so the normal squamous epithelium is replaced by gastric or intestinal type mucosa)

6

7 Barrett mucosa/ the red tongues

8

9 Barrett/ note the squamous epithelium on the right and the intestinal metaplasia on the left

10 Barrett / note the goblet cells ( mucus secreting cells with white vacuoles)

11 Complications of Barrett: dysplasia and carcinoma

12 Metaplasia can predispose to malignancy. this usually occurs through transforming to dysplasia first. Dysplasia is an abnormal organisation of the mucosa without invasion. in Barrett s mucosa dysplasia manifests as hyperchromasia, stratification, cigar shaped nuclei and increased mitotic activity. Allthese changes are restricted to the lining of the glands with no invasion. Dysplasia can be low or high grade. Risk of invasive malignancy is higher with high grade dysplasia.

13

14 Esophageal tumors The majority of esophageal malignancies are : adenocarcinomas and squamous cell carcinomas Squamous cell carcinoma (SCC) was the most common type, but with increased GERD and Barrett esophagus, adenocarcinoma has increased and it is now commoner than SCC at least in the West

15 Jordan cancer registry 2013 statistics number % of overall cancers males % females % overall %

16 adenocarcinoma Risk factors: GERD and Barrett mucosa Smoking Obesity Previous radiotherapy Risk is reduced with diets rich in fruit and veg

17 Adenocarcinoma/epidemiology Male to female ratio 7: 1 Highest rates in USA, UK, Canada, Australia Lowest incidence in Korea, japan and Thailand Before 1970 adenocarcinoma represented less than 5% of esophageal tumors, but ow it accounts for at least 50% of esophageal tumors!! Cause: GERD due to dietary changes SO DON T EAT UNHEALTHY FOOD.!!

18 pathogenesis Barrett epithelium acquires several genetic mutations over a long period of time to transform to adenocarcinoma A common mutation is the TP53 mutation Inflammation also acts as an enabler of malignant transformatin

19 Complications of Barrett: dysplasia and carcinoma

20 morphology Adenocarcinoma affects the distal third of the esophagus (which is the site of Barrett) Gross appearance: exophytic masses or ulcers Microscopy: tumor forming glands and producing mucin

21 Clinical features Pain or difficulty in swallowing Weight loss Chest pain vomiting

22 prognosis Depends on stage (extent of invasion and spread ) 5 year survival 80% if the tumor is limited to the mucosa or submucosa 5 year survival is 25% if the disease is advanced.

23 Morphology: adenocarcinoma presents as a mass or polyp at the gastroesophegeal junction.

24 Adenocarcinoma

25 Adenocarcinoma: note the location at the lower part of the oesophagus, usually at the gastroesophageal junction.

26 adenocarcinoma: abnormal glands invading the mucosa, submucosa and muscle.

27 Squamous cell carcinoma Affects adults older than 45 Male: female ratio is 4:1 Risk factors: alcohol, smoking, poverty, caustic injury, achalasia, frequent consumption of very hot drinks, previous radiotherapy. Higher incidence in : Iran, china, Hong Kong

28 morphology Usually in the middle third of the esophagus Starts as squamous dysplasia SCC appears usually as a polypoid mass They spread to adjacent structures and to lymph nodes early in their development because of the rich lymphatic supply

29 Note the tumor location in the midesophagus

30 SCC

31 Clinical picture Dysphagia ( difficulty in swallowing ) Odynophagia ( pain on swallowing) Weight loss

32 prognosis 5 year survival= 75% if tumor is superficial and didn t spread Much worse prognosis if advanced Overall 5 year survival is 9%, because the majority of cases are discovered at a late stage.

33 Early detection is important in esophageal tumours. Many oesophageal tumours can be prevented by changing life style.

34