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Describes the pathology of the common diseases of the oesophagus, stomach, and appendix.
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OESOPHAGUS AND STOMACH
Lecture Outline
Oesophagus– Premalignant non-neoplastic disorders– Neoplasms– Causes of upper GI Haemorrhage
Stomach– Inflammatory disorders– Neoplasms
Oesophagus Congenital Abnormalities
– Plummer - Vinson Syndrome (Paterson - Kelly)
Webs Fe deficiency anaemia Atrophic glossitis
risk of malignancy
Oesophagus
Achalasia Cardia Decreased/loss of myenteric ganglion cells
– Aperistalsis resting tone LES
Dilatation Stasis Inflammation
– Neoplasia (5%)
Oesophagitis Reflux
– Bleeding– Ulceration– Stricture LES tone, alcohol, pregnancy, CNS
depression, obesity– Columnar metaplasia (Barrett’s)
10% risk of malignancy Infectious
– Candida- AIDS
Oesophageal Varices Porto-systemic anastomosis
– Cirrhosis– Bud-Chiari syndrome– Hepatic vein thrombosis– Portal vein thrombosis– Veno-occlusive disease (VOD)
Complication– Rupture- <50% of UGI bleed– Cause of death of 50% of
alcoholics
Mallory-Weiss Syndrome Longitudinal tears at GEJ
– Partial or complete thickness Severe retching Alcoholic 5-10% of UGI bleed
Oesophageal Tumour
Benign– Leiomyomas
Malignant– Squamous cell carcinoma (90%)– Adenocarcinoma (10%)
Oesophageal Carcinoma6% of GIT cancers SCC
– >50 M:F= 2:1 B>W– Dietary factors
Vitamin deficiencies Zn deficiency Nitrites/nitroamines
– Lifestyle Cigarette Alcohol
Oesophageal Carcinoma Location (SCC)
– Middle1/3 -50%– Lower 1/3 –30%– Upper 1/3 –20%
Morphology– Polypoid/exophytic –60%– Excavating –25%– Flat –15%
Oesophageal Carcinoma
Adenocarcinoma– Barrett’s metaplasia*– Submucosal glands
Microscopy– SCC - keratin– Adeno – glands mucin
Stomach Gastritis
– Acute– Chronic
Acute – Superficial acute inflammation haemorrhage polymorphs superficial erosion
Acute Gastritis
Pathogenesis acid secretion HCO3
-
blood flow mucosal barrier
Acute GastritisAetiology NSAID/Aspirin
Alcohol Smoking ChemoRx drugs Uremia
•Stress•Trauma•Burns – Curling’s•Head injury – Cushing’s•Surgery
•Shock•Ischaemia•Sepsis
Acute Gastritis
Clinical Features Asymptomatic Pain Nausea/vomiting Haematemesis Melaema
Chronic GastritisAetiology Helicobacter pylori (90%)
Autoimmune (<10%)– Pernicious anaemia
Toxins - ETOH, Smoking
Bile Reflux (post-gastrectomy)
Chronic GastritisMorphology Autoimmune (type A)
– Diffuse, body and fundus– More severe– Atrophy, auto-antibodies & parietal cell loss
H. pylori-associated (type B)– Focal or diffuse, antral and body– Polymorph infiltration– Lymphoid nodule formation
Chronic Gastritis Chronic mucosal inflammation
– Superficial or deep mucosal atrophy intestinal metaplasia No erosion
Gastric Tumours Benign
– Leiomyomas– Adenomas
Malignant– Adenocarcinoma (>90%)– Lymphomas (4%)– Endocrine cell tumours (3%)– Stromal tumours (2%)
Gastric Carcinoma M:F =2:1 Japan, Chile, Costa Rica Predisposing factors
– Environmental factors Diet
– preserved/smoked/salted foods fresh fruits and vegetables
Low socioeconomic status Cigarette smoking
Gastric Carcinoma Host factors
– CGIM ± H pylori– Partial gastrectomy– Adenomas
Genetic factors– Bld grp A– Family Hx– Lynch syndrome (HNPCC)
Gastric CarcinomaClassification Depth of invasion
– Early (95% 5YS) mucosal & submucosal LN
– Advanced (<15% 5YS) Morphology
– Exophytic– Flat (linitis plastica)– Excavated
Gastric CarcinomaClassification Histologic Types (Lauren Classification)
– Intestinal CGIM ± H pylori M:F =2:1, 55y
– Diffuse Spontaneous M:F =1:1, 48y
GIT Mesenchymal Tumours
Differentiation Stromal Tumours
(GIST) Smooth Muscle
(Leiomyosarcoma) Neurogenic
Causes of Upper GI Haemorrhage
SpecificOesophageal Gastric Varices Acute Gastritis Mallory Weiss Ulcers Neoplasia
Duodenal Ulcers
Non-specific
SMALL INTESTINE AND APPENDIX
Lecture OutlineSmall Bowel Peptic ulcer disease Causes and mechanisms of diarrhoea Clinicopathologic features of Crohns disease NeoplasmsAppendix Appendicitis Neoplasms and Multiple Endocrine
Adenopathy syndrome
Peptic Ulcer
Area of acid/pepsin digestion Relative or absolute acidity
Acid Secretion vs Mucosal Barrier
Peptic UlcerArea of acid/pepsin digestion Duodenum (70-75%) Antrum (20-25%) GEJ Multiple – ZE Meckel’s diverticulumRelative or absolute acidity vs mucosal
barrier
Peptic UlcerAetiologyM>F DU =3:1 GU =2:1 H. Pylori
– DU - 95%– GU –70%
NSAIDs (GU) Zollinger - Ellison Syndrome Other
Peptic UlcerMorphology <4cm Round/oval, punched out margins Clean base GU
– Lesser curve, antrum– Radiating rugal fold
DU– 1st part
Peptic Ulcer
Histology Fibrin and necrotic debris Non-specific inflammation Granulation tissue Scar tissue (fibrosis)
Peptic Ulcer
Complication Bleeding Perforation Obstruction Intractable pain ? Malignant change
– GU - <1%– DU - never
Enterocolitis
Diarrhoea mass, frequency and fluidity
DysenteryPainful, bloody diarrhoea( +low volume )
Diarrhoeal Disorders
Secretory Osmotic Exudative* Deranged Motility Malabsorption*
Infectious Enterocolitis
Viruses Rota - Infants Norwalk - Child., Adults Adeno
Damaged mature enterocytes are replaced by immature secretory cells => secretory and osmotic diarrhoea.
Bacterial Enterocolitis Preformed Toxins S. aureus, Vidrios, C. perfringens
Enterotoxins E. coli, V. cholerae
Enteroinvasive Salmonella, Shigella, C. jejuni, Yersinia
Parasitic Enterocolitis Protozoa
GiardiaCryptosporidia
HelminthsStrongyloidesAscarisHookworm
Malabsorption
Definition Sub-optimal absorption of fat, fat-soluble
and other vitamins, protein, carbohydrate, electrolytes, minerals and water.
Malabsorption Syndrome
Symptoms Diarrhoea - Bulky, Frothy, Greasy Weight Loss Abdominal Distention Borborygmi
MalabsorptionConsequences GIT - Diarrhoea Blood - Anaemia ( Fe, B12, Folate )
- Bleeding Musculoskeletal - Osteopenia, Tetany
(Ca, Mg, Vit D, Protein ) Endocrine Skin Nervous System
MalabsorptionCommon Causes
USA - celiac sprue- chronic pancreatitis- crohn’s disease
Ja - chronic pancreatitis
Unusual Causes Celiac disease (Gluten-sensitive enteropathy,
Nontropical sprue)– Rare in nonwhites
Tropical Sprue (Post-infectious Sprue)– Caribbean (not Ja), South and Central America
Whipple’s Disease– Whites 30 - 40 yrs
GIT AND HIV Malabsorption
Infectioncryptosporidia shigellaisospora CMVsalmonella HSV
Crohn’s Disease(Terminal ileitis, Regional enteritis)
Inflammatory Bowel Disease Chronic relapsing Granulomatous Unknown aetiology
Crohn’s Disease
Mouth to anus Genetic determinants: HLA-B27 ? infectious ? immune mediated Any age peaks 50 - 60 F > M white = 2 - 5x nonwhites Jews 2 - 5x non-Jews
Crohn’s Disease Transmural inflammation Segmental Noncaseating granulomas 50% Fissures and fistulas Mural fibrosis and strictures Creeping fat Lymphadenopathy Systemic manifestations
IBD Extra-GI Manifestations
Migratory polyarthritis
Sacroiliitis
Ankylosing spondylitis
Erythema nodosum
Clubbing
Small Intestine Tumours3 - 6 % of GIT tumours Benign
– Leiomyomas– Adenomas– Lipomas
Malignant– Adenocarcinomas– Endocrine cell tumours– Lymphomas– Stromal tumours
Endocrine Cell Tumours(Carcinoids)
Slow growing
Low malignant potential– “benign” - appendix, rectum– “malignant” - ileum, stomach, colon
Hamartomatous Polyps
Peutz Jegher/ Syndromemuscularis mucosa
Juvenile/ Syndromelamina propria(colon)
APPENDIX
Acute Appendicitis
Luminal obstruction(fecolith, tumour, worms)
Increased intraluminal pressure
Mucosal ischaemia
2o bacterial colonization
Acute Appendicitis
Morphology suppurative gangrenous empyema
Complications abscess perforation peritonitis septicaemia mucocele
Acute Appendicitis Mesenteric adenitis ( yersinia, virus )
Acute salpingitis
Ectopic gestation
Mittelschmerz
Meckel’s diverticulitis
Appendix Tumours
Mucinous cystadenoma/ carcinoma- pseudomyxoma peritonei
ECT - carcinoid
Adenocarcinoma
Multiple Endocrine Adenopathy (Neoplasia)
Hyperplasia and neoplasia of more than one endocrine gland
Autosomal dominant ( some recessive )
3 syndromes
MEA
I
pituitaryparathyroidpancreasadrenalPUD
II
pheomedullary ca
III
pheomedullary caganglioneuro
osteoma