Upper GI Pathology

Question 1

What are the normal structures of the upper GI tract? Describe them

Answer 1

Oesophagus

• Squamous epithelium top 2/3
• Columnar epithelium bottom 1/3
• Joined at ‘Z line’

Stomach

• Fundus and body have specialised cells (gastric mucosa, lamina propria, muscularis)
• Antral

Duodenum

• Glandular epitheliu, with goblet cells
• Villous architecture
• Villi:crypt is normally >2:1

Question 2

Describe the pathology of the diseases of the oesophagus

Answer 2

Reflux disease

• Most common cause of oesophagitis
• Red and swollen oesophagus
• Causes ulceration, haemorrhage, perforation, Barrett’s
• Treated with lifestyle changes and PPI/H2 antagonists

Barrett’s oesophagus

• Seen in 10% of those with symptomatic reflux disease
• Metaplasia of the squamous epithelium (into gastric or intestinal tissue)
• Migration of the Z-line upwards
• Has a cancer risk (higher in intestinal metaplasia)

Oesophageal adenocarcinoma

• Most common oesophageal cancer in the UK
• Associated with Barrett’s (seen in bottom 1/3)
• Risk factors: smoking, radiation

Squamous cell oesophageal carcinoma

• Most common oesophageal cancer worldwide
• Associated with ETOH, smoking
• Usually found in middle 1/3 of oesophagus
• Progressive dysphagia, weight loss, anorexia
• Poor prognosis

Varices

• As a result of portal hypertension (cirrhosis, portal vein thrombosis)
• Engorged veins that can rupture
• Massive haematemesis
• Treated with emergency endoscopy

Question 3

Name and describe the pathology of the diseases in the stomach

Answer 3

Gastritis

• Acute: aspirin, NSAIDs, bleach
• Chronic: H. pylori, autoimmune, chemical
• Complicates into ulcer formation
• Complicates into metaplasia

Gastric ulcer

• Definition: breach through into muscularis layer
• Epigastric pain (worse with eating) and weight loss
• Associated with H.pylori, NSAIDs, stress
• Pathology shows punched out margin with rolled margins
• Investigate for H. pylori
• Complicated into anaemia, perforation, malignancy

Gastric cancer

• H. pylori increases cancer risk by 8 times
• > 95% of cancers are adenocarcinomas (can be intestinal or diffuse)
• 5% are SCCs, GI stromal tumours, neuroendocrine or MALT
• Gastric lymphoma is a B cell lymphoma associated with H. pylori (treated with triple therapy: PPI, clarithromycin, amoxacillin/metronidazole)

Question 4

Name and describe the pathology of the diseases in the duodenum

Answer 4

Duodenal ulcers

• 4 times more common than gastric ulcers
• Epigastric pain (relieved by eating)
• Associated with H. pylori, aspirin, NSAIDs, steroids
• Also associated with CMV, giardia, Whipple’s disease
• Complicates into anaemia and perforation
• Can exhibit gastric metaplasia

Coeliac disease

• T cell mediated autoimmune destruction of the villi
• Results in gluten intolerance and villous atrophy and malabsorption
• Presents in childhood with failure to thrive, steatorrhea, abdo pain, bloating
• Investigated with anti-endomysial antibodies and anti-tissue transglutaminase antibodies
• Diagnosed on biopsy: villous atrophy and crypt hyperplasia
• Treated by excluding gluten from diet