GASTROINTESTINAL TRACT Presented by Prof.ZEINAB SHEHAB EL DIN
ILO s By the end of this lecture students should be able to: Identify types of stomatitis. Define leucoplakia and list its causes. Enumerate ulcers and tumours of the oral cavity. Define sialoadenitis and identify its types. Classify tumours of the salivary glands and describe the pathologic features of each.
DISEASES OF THE ORAL CAVITY:MOUTH Stomatitis: Inflammation of the oral mucosa 1. Catarrhal 2. Aphthous:Mycoplasma 3. Bacterial: -TB-Syphilis 4. Fungal: Candidiasis 5. Viral: Herpes simplex 6. Agranulocytic Angina 7. Dyspeptic: small painful ulcer due to GIT disturbances 8. Mercurial, arsenical compounds: mucosal ulcers
TYPES OF STOMATITIS 2. Aphthous Stomatitis :common in young adult ( in 40%) Causes: 1. Unknown 2. Allergic: cell mediated immune reaction 3. Mycoplasma 4. Vitamin B or Iron deficiency. Lesions: 1. Small vesicles on: lips, edges of tongue, inside the cheeks rupture of vesicles 2. Small shallow painful ulcers, round/oval on lips buccal mucosa or tongue 3. Ulcers resolve in 15 days-may reccur later
Bacterial Stomatitis 1) Syphilis: Congenital : Fissure at the angle of the mouth Acquired:Chancre in primary syphilis(raised nodule) Mucus patch ulceration in secondary $ Gumma(localised area of necrosis) in hard or soft palate 2)T.B: In advanced pulmonary TB Lesions:small nodule on gingiva or buccal mucosa Followed by TB ulcer with undermined edge
TYPES OF STOMATITIS 3.Candidiasis(Thrush): Causes: Candida albicans(normal commensals) In High risk patients: newborn, diabetics,chemotherapy/antibiotics,immunosuppressed Lesions: Inflammation, edema White patches (fungus filaments matted in fibrinosuppurative exudate covering necrotic epithelium) ulcerate when rubbed
TYPES OF STOMATITIS Viral Herpetic Stomatitis: Causes: Herpes simplex virus, type I( more common) & II. Lesions: Associated with upper respiratory tract infection,immunosuppression and exposure to extreme temperature Mucosal vesicular eruptions on gingiva, lips, palate and tongue
TYPES OF STOMATITIS Agranulocytic Angina: Causes: Low total leucocytic count below 1000/cmm Low resistance Lesions: Inflammation of gums and mucous membrane of mouth and nasopharynx. Necrosis and ulceration.
PRECANCEROUS LESIONS LEUKOPLAKIA: Caused by: chronic irritation excessive smoking, ragged teeth &bad fitting denture Gross: White thick patch with sharp outlines (buccal mucosa, molar region, corners of the mouth, lips, palate & lateral borders of tongue MP: Acanthosis Hyperkeratosis Diffuse chronic inflammation& fibrosis ERYTHROPLAKIA: Causes: Unknown-Not related to inflammation Gross: Velvety Red patches MP: Acanthosis Lack of keratin Underlying blood vessels show through the epithelium
Cause: Unknown (? smoking) Gross picture: Whitish plaques
Microscopic picture: 1. Hyperkeratosis 2. Parakeratosis 3. Acanthosis 4. Atypia It is precancerous
BENIGN TUMOURS OF THE MOUTH Squamous cell papilloma Cavernous haemangioma] Congenital Cavernous lymphangioma] Hamartomas Granular cell tumour (Myoblastoma) Adenomas of minor salivary glands*:basal cell A Fibroma and lipoma :rare Dermoid cyst: may develop under the tongue *Minor salivary glands present in practically all structures within the oral cavity
SQUAMOUS CELL PAPILLOMA PRECANCEROUS Occur on tongue or lips Grossly:finger like polypoid projection Micoscopically: Folds of epithelial proliferation Acanthosis Parakeratosis Elongation of rete ridges Fibrous tissue Core
Cavernous Haemangioma & Lymphangioma Hamartomas Dating since birth Affects lip Macrochelia Affects tongue Macroglossia
Basal Cell Adenoma of minor salivary glands
Malignant Tumours of the Mouth CARCINOMA Risk Factors &Precancerous Lesions: 1. Leukoplakia and erythroplakia. 2. Squamous cell papilloma 3. Tobacco Smoking. 4. Alcohol 5. Viruses (HPV type 16) 6. Ch irritation by ragged tooth Site: Common: Anterior two thirds and Lateral border of tongue Floor of mouth Lower lip Rare: Soft Palate, gingiva Dorsum of tongue Epidemiology: More in males above 50ys
Carcinoma of the Mouth Grossly: Local area of induration Infiltrating hard nodule Typical malignant ulcer Rarely a polypoid mass on dorsum of the tongue Microscopically: Squamous cell carcinoma Low grade in ant 2/3 High grade in post 1/3
Carcinoma of the Mouth Spread: is rapid due to Rich lymphatic drainage of the tongue Constant muscular movement 1. Local spread: fix the tongue to floor of mouth 2. Lymphatic spread:to 1. Submental,submaxillary LN 2. Superior and Inf.deep cervical LN NB:in post 1/3 cancer bil.deep cx LN are involved Blood spread :rare and late
Carcinoma of the Mouth Effects and complications:( FICH) 1. Fixation of tongue leads to dysphagia, dysarthria and saliva dribbling. 2. 2 nd pyogenic infection leading to aspiration pneumonia and lung abcess. 3. Cancer cachexia (Loss of weight +Anaemia) 4. Haemorrhage.
Ulcers of the Tongue** 1. Traumatic ulcer: Tip & edgeshallow infected with ragged tooth 2. Dyspeptic ulcer :Tip &edgeshallow,painful,of short duration. 3. Tuberculous ulcer : Tip& baseundermind edge with caseation & tubercles. Complication of open Pulmonary.TB. 4. Syphilitic ulcer: Dorsum- Chancre,mucus patch or ulcerated gumma. edges punched out 5. Malignant ulcer: Edge &dorsumraised everted edges, indurated base,necrotic infected floor.
Malignant Ulcer
Diseases of Salivary Glands Sialoadenitis: Inflammation of SG 1. Mumps (Viral). 2. Acute suppurative parotitis (bacterial). 3. Sjogren s syndrome (autoimmune ). Sialolithiasis: Common in submandibular duct(other glands have watery secretion). Stone= nidus of desquamated ductal epithelium+inspicated secretion+calcium phosphate concretion Pain,gland enlargement during meal Predispose to suppurative inflammation
Sialoadenitis Mumps Cause: Virus Mode of infection: Droplet Clinically:3wks incubation period Parotid enlargement, bilat. Local pain, fever, malaise Lesion:Non supp.inflam, edema, mononuclear cell infiltrate (lymphocytes. Complications: In children: self limited Orchitis (in adult) Oophoritis Pancreatitis ( rare) Encephalitis (rare) Acute Suppurative Parotitis: Cause:Staph &strept from mouth through stensen s duct or haematogenous Clinically: Unilateral involvement Lesion: Gland enlarged Hyperaemic Pus formation Sjogren s Syndrome: Immune mediated destruction of: Lacrymal Gl: Dry eye Keratoconjuctivitis sicca Salivary Gl:Dry mouth Xerostomia
Suppurative sialoadenitis
Tumours of Salivary Glands Benign Tumours: 1. Pleomorphic adenoma 2. Papillary cystadenoma lymphomatosum (Warthin s T) 3. Oncocytoma 4. Haemangioma & lymphangioma Malignant Tumours: 1. Mucoepidermoid C 2. Adenoid cystic carcinoma 3. Carcinoma in pleomorphic adenoma 4. Undifferentiated C
1.Pleomorphic Adenoma Commonest salivary G T, more 50%,more in female parotid till 40 s Grossly:Encapsulated Grayish white cut surface May be :Cystic/multinodular Microscopically: Solid sheets of epithelial cells Spindle myoepithelial cells & lymphoid tissue Myxomatous CT matrix Cartilage ***Recurrence rate is high although encapsulated due to extracapsular budding of epithelium.
Benign mixed tumor. The myoepithelial cells are undergoing cartilaginous metaplasia.
2.Papillary Cystadenoma Lymphomatosum(Warthin s Tumour) In elderly Male Parotid Grossly: Encapsulated Cystic areas on cut section Microscopically: Cystic space with papillary projections covered by oncocytes Sheets of lymphocytes,plasma cells forming germinal center
Malignant Tumours 1.Mucoepidermoid Carcinoma 5%of ST Common in Parotid(67%) Gross: Low grade(cystic) & High grade (Solid) malignancy well circumscribed solid with cysts containing mucine Microscopically:3 cell types Mucous secreting Epidermoid Intermediate Low G:50%mucous cells HighG:Mainly undif. Intermediate / poorly differentiated epidermoid cells Spread; regional LN in High G
Malignant Tumours 2.Adenoid Cystic Carcinoma 10%of SGT Comonest Malignant SGT Common in submandibular and minor SG Slowly growing aggressive Gross: White, glistening, infiltrating Microscopic: Classic cribriform type Sheets of monomorphic hyperchromatic cells arround tubules or in Swiss cheese pattern Pseudocyst filled with esinophilic PAS + material
3.Carcinoma in Pleomorphic Adenoma Gross: Foci of hge, necrosis, calcification & or hyalinisation. Microscopically: may be Adenocarcinoma Squamous cell carcinoma Undifferentiated carcinoma Carcinosarcoma (chondrosarcoma)
Diseases of the Pharynx Pharyngitis: 1. Aphthous 2. Herpetic 3. Vincent angina 4. Agranulocytic angina 5. Candidiasis 6. Syphilis Benign Tumours Squamous cell papilloma Nasopharyngeal angiofibroma Pleomorphic adenoma Teratoma Malignant Tumours: Squamous cell carcinoma Lymphoepithelioma
Tumours of the Pharynx Nasopharyngeal angiofibroma: Male 15-25ys Gross:large,vascular,spongy Micros:spindle cells +many thin walled blood vessels
Lymphoepithelioma(Undif.Carcinoma) Adult/children male.60/20 ys Metastasize early to cervical LN,lung, liver,bone Micros: masses of undifferentiated epithelial cells surrounded by lymphocytes
QUIZ 1) Define Agranulocytosis List its effect on the oral cavity 2) List the Precancerous lesions of the oral cavity.