ESOPHAGUS

ESOPHAGUS

Normal Anatomy Muscular tube, 25 cm in length in adults.

Extending from the upper esophageal sphincter at 15-18 c m from the incisors to lower esophageal sphincter at 40 c m (variable).

Histology Lined by stratified squamous non-keratinized epithelium.

Basal layer 4 cell thick; not more than 15% of total epithelial thickness. Melanocytes & neuroendocrine cells maybe found

Lamina propria: mucous glands in distal portion (cardiac glands)

Muscularis Mucosae: Thicker than other parts of GIT

Submucosa: Submucosal glands

ESOPHAGUS

Muscularis propria: Admixture of striated & smooth muscle in the upper quarter, only smooth muscle in the rest of the organ.

No serosal layer, except for the most distal portion.

Autonomic nervous system: Meissner’s plexus in submucosa Auerbach (Myenteric) plexus in muscularis propria

Lymphatics: Upper third drains into cervical nodes, middle third into paraesophageal & paratracheal nodes, & lower third into nodes around aorta & celiac axis.

Normal Esophagus

ESOPHAGITIS

CHEMICAL AND INFECTIOUS

REFLUX

EOSINOPHILIC

CHEMICAL AND INFECTIOUS

ESOPHAGITIS

Alcohol, acids, alkalis, excessively hot fluids

Heavy smoking

Pill induced

Chemotherapy, radiotherapy

Graft versus host disease

HSV, CMV, FUNGAL

Desquamative skin diseases

Morphology

Ulceration

Necrosis

Granulation tissue

Fibrosis

Herpetic ulcer

HERPES SIMPLEX

ESOPHAGITIS

CMV

ESOPHAGEAL CANDIDIASIS

CANDIDIASIS

Candidiasis PAS & GMS Stain

Reflux Esophagitis

GERD: gastroesophageal reflux disease

Pathogenesis

Reflux of gastric juice

Reflux of bile may occur

Decreased lower esophageal tone

Increased abdominal pressure

SYMPTOMS

Dysphagia

Heartburn

Regurgitation

Severe chest pain

Morphology

Hyperemia

Eosinophils, Neutrophils

Basal zone hyperplasia

Reflux Esophagitis

Barrett esophagus

Complication of chronic GERD

INTESTINAL METAPLASIA within

squamous mucosa

Increased risk of esophageal carcinoma

Endoscopy

Long segment ( 3 cm or more )

Short segmnt ( less than 3 cm )

Tongues of red velvety mucosa extending upward from GE junction

Morphology

Intestinal metaplasia, goblet cells

Dysplasia, precancerous

Barrett Esophagus

BARRETT ESOPHAGUS

LOW GRADE DYSPLASIA

HIGH GRADE DYSPLASIA

INTRAMUCOSAL CARCINOMA

Adenocarcinoma

Barrett esophagus

Longstanding GERD

Tobacco, obesity, radiation

Decreased fresh fruit and vegetables

Seven times more in males

Dysphagia, weight loss, hematemesis, chest pain,

vomiting

Distal third of esophagus

Flat, raised, 5 cm or more mass

Infiltrative, deep ulcer

Intestinal type carcinoma

Signet ring type

Squamous cell carcinoma

Epidemiology

Most frequent in men , over 45 yrs of age

Male to female ratio is 4:1

Blacks are at higher risk than whites

Relatively common in China, Iran, Southern Brazil and other oriental countries, most common tumor of alimentary tract in African Bantus

In western countries, there has been a recent epidemiologic switch from tobacco and alcohol-related SCC to Barrett’s-related adenocarcinoma.

Associated Factors in Development of SCC of

Esophagus

Betel chewing

Deficiency of vitamins

Deficiency of trace elements

Fungal contamination of foodstuffs

High content of nitrites/nitrosamines

Lifestyle

Burning-hot beverages or food

Alcohol consumption

Tobacco use

Rural environment

Esophageal Disorders

Caustic injury

Achalasia

Plummer-Vinson syndrome

Genetic Predisposition

P53 and p16INK4 mutations

Morphologic features and local spread: Occur in any part of esophagus, most common in middle

50% and lower thirds30%

Grossly

Intraepithelial neoplasia (EIN) or carcinoma-in-situ

Early lesion small grey white plaque like thickenings or elevation of mucosa

Late circumferential tumour mass, often ulcerated with sharply demarcated margins

Three morphologic pattern:

1. Exophytic or polypoid

2. Flat , Diffuse thickening of wall with narrowing of lumen

3. Ulcerated

Morphology

Well differentiated

Moderately differentiated

Poorly differentiated

SQUAMOUS CELL

CARCINOMA