Upper GI Pathology

Question 1

What are the layers of the gut?

Answer 1

Question 2

What is the Z line?

Answer 2

Transitional line from squamous to columnar

Question 3

What are the parts of a normal stomach?

Answer 3

Question 4

What are the layers of the stomach in the body?

Answer 4

Question 5

What are the layers of the stomach in the antrum?

Answer 5

Question 6

What is normal duodenal epithelium?

Answer 6

Question 7

What is this?

Answer 7

Acute oesophagitis

Question 8

What is the presentation and complications of GORD?

Answer 8

• Gastro-oesophageal reflux disease
• Commonest cause of oesophagitis
• Reflux of acidic gastric contents

Ulceration

–necrotic slough

–inflammatory exudate

–granulation tissue

•Fibrosis

Complications

• haemorrhage
• perforation
• stricture
• Barrett’s oesophagus

Question 9

What is this?

Answer 9

BARRETT’S OESOPHAGUS

•Re-epithelialisation by metaplastic columnar epithelium usually with goblet cells
(intestinal type epithelium)

•AKA columnar lined oesophagus (CLO)

Question 10

What is 1,2 and 3?

Answer 10

1. Normal
2. CLO
3. CLO with IM

Question 11

What changes lead to cancer?

Answer 11

Metaplastic glandular epithelium (intestinal type)

Dysplasia changes showing some of the cytological and histological features of malignancy but no invasion through the basement membrane

Adenocarcinoma invasion through the basement membrane

Question 12

What is the most common type of oesophageal cancer?

Answer 12

Adenocarcinoma of the oesophagus (lower- associated with reflux)

Question 13

What is this?

Answer 13

• Associated with alcohol and smoking
• Mid/lower oesophagus
• Invasion into the submucosa

Question 14

What is this?

Answer 14

SCC of oesophagus

Question 15

What is the prognosis of an oesophageal carcinoma?

Answer 15

• Prognosis poor
• Diagnosis of pre-invasive stage important

Question 16

What is the oesophageal varices?

Answer 16

caused by: cirrhosis, Budd Chiari/ PV thrombosis

Question 17

What is gastritis?

Answer 17

• inflammation of the gastric mucosa
• Acute gastritis - acute insult
• Chronic gastritis - chronic / persistent insult

Question 18

What might cause acute gastritis?

Answer 18

Chemical

• aspirin/NSAIDs
• alcohol
• corrosives

Infection

e.g. Helicobacter pylori

Question 19

What causes chronic gastritis?

Answer 19

• H. pylori associated
• Chemical (NSAIDs, bile reflux; antrum )
• Autoimmune (body, auto-antibodies e.g. antiparietal)
• Lymphocytes +/- Neutrophils

Mucosal Associated Lymphoid Tissue (MALT)induction

Question 20

What is H Pylori associated gastritis?

Answer 20

•Cause

H. pylori

•Pattern

chronic gastritis +/- activity

•Outcome

CLO-IM-Dysplasia,

Adenocarcinoma

Lymphoma (MALToma)

Question 21

How is Helicobacter a carcinogen?

Answer 21

• Helicobacter infection is associated with an 8x increased risk of (non-cardia) gastric cancer
• cag-A-positive H.pylori have a needle like appendage that injects toxin into intercellular junctions allowing the bacteria to attach more easily.
• This strain is associated with more chronic inflammation.
• Treatment of the infection with antibiotics drastically reduces the risk of cancer.

Question 22

What else causes gastritis?

Answer 22

•Infection

e.g. CMV, strongyloides

(immunosuppression)

•Inflammatory bowel disease

Crohn’s Disease

Question 23

What is this?

Answer 23

Gastric ulcers

All ulcers should be biopsied to exclude malignancy

Question 24

What are the complications of ulcers?

Answer 24

•Bleeding

Anaemia

Shock (massive haemorrhage)

•Perforation

Peritonitis

Question 25

What is intestinal metaplasia?

Answer 25

* As in the oesophagus: * intestinal metaplasia in gastric mucosa in response to long term damage * Increased cancer risk

Question 26

What is gastric epithelial dysplasia?

Answer 26

* Abnormal epithelial pattern of growth * Some of the cytological and histological features of malignancy are present, but no invasive through the basement membrane

Question 27

What are factors contributing to gastric cancer?

Answer 27

Question 28

Who gets gastric cancer?

Answer 28

* High incidence in Japan, Chile, Italy, China, Portugal, Russia * More common in men (1.8:1 ♂:♀) * \>95% of all malignant tumors in stomach are adenocarcinomas

Question 29

What type of cancers are gastric cancers?

Answer 29

95% of stomach cancers are adenocarcinoma These are split morphologically into: * Intestinal – well differentiated * Diffuse – poorly differentiated (Linitis plastica), includes signet ring cell carcinoma * The remaining 5% is made up of: –Squamous cell carcinoma –Lymphoma (MALToma) [Haematology] –Gastrointestinal stromal tumour (GIST) [Endocrinology] –Neuroendocrine tumours [Endocrinology] •Overall survival rate is 15%

Question 30

What is gastric lymphoma?

Answer 30

•Chronic inflammation –Chronic immune stimulation * B cell (marginal zone) lymphocytes * Treatment –If limited to the stomach and H.pylori is present: H.pylori eradication

Question 31

What is duodenitis?

Answer 31

* Increased acid production in the stomach which spills over into duodenum * Chronic inflammation and gastric metaplasia with helicobacter infection

Question 32

What is a duodenal ulcer?

Answer 32

Duodenitis and DU good correlation between endoscopy and biopsy pathology Endoscopy “itis”: 73.5% progress to ulcer, mainly erosive duodenitis (biopsy – neutrophils)

Question 33

What other pathogens can cause a duodenal ulcer?

Answer 33

* Immunosuppressed * CMV * Cryptosporidiosis * Giardia lamblia infection * Whipple’s disease -Tropheryma whippelii.

Question 34

What causes malabsorption in partial villous atrophy?

Answer 34

* Histology * Villous atrophy * Crypt hyperplasia * Increased Intraepithelial lymphocytes (normal range less than 20 lymphocytes /100 enterocytes)

Question 35

What does the second half of this image show?

Answer 35

Flattening in villous atrophy

Question 36

What is required for the diagnosis of coeliac disease?

Answer 36

•Diagnosis requires: endomysial antibodies and tissue transglutaminase antibodies Duodenal biopsies: On gluten rich diet showing villous atrophy Off gluten showing normal villi There are other causes of malabsorption with similar histology e.g. tropical sprue

Question 37

What is a duodenal MALToma?

Answer 37

Patients with coeliac disease have an increased risk of GIT cancers * MALToma associated with Coeliac is * in the duodenum * T-cell origin * (Enteropathy Associated T-cell Lymphoma)

Question 38

What is this?

Answer 38

Duodenal maltoma

Question 40

What are the 2 types of Barretts?

Answer 40

Without gobelt cells (gastric metaplasia) With goblets cells (intestinal metaplasia)

Question 41

What is CLO?

Answer 41

Barrett's oesophagus (metaplastic change in oesophagus)

Question 42

What is associated with SCC of the oesophagus?

Answer 42

Commonest in developing countries Associated with alcohol and smoking Mid/ lower oesophagus

Question 43

Do cancers arise from pre existing adenomas in the oesophagus and stomach?

Answer 43

No (but this is not true in colon)

Question 44

In a patient with coeliac disease on a diet containing gluten, which is the most likely histological change in the duodenum?

Answer 44

Villous atrophy, increased intra-epithelial lymphocytes