Esophagus

NORMAL ESOPHAGUS

NORMAL ENDOSCOPIC VIEW OF ESOPHAGUS

NORMAL HISTOLOGY OF ESOPHAGUS

ENDOSCOPIC VIEW OF ESOPHAGEO GASTRIC

SYMPTOMATOLOGY OF ESOPHAGEAL DISEASES • • • •

Heart burn Dysphagia Pain Hematemesis

CONGENITAL ANOMALIES • Ectopic tissue rests – stomach, pancreas • Congenital cysts – lower esophagus usually • Bronchogenic cyst • Pulmonary sequestration • Agenesis • Atresias and fistulas

ATRESIAS AND FISTULAS • ATRESIA – esophagus represented as a thin non canalized cord • Proximal blind pouch connected to pharynx • Distal lower pouch leading to stomach • Most commonly occurs at or near the tracheal bifurcation • Usually associated with a fistula –

ATRESIAS AND FISTULAS • SINGLE UMBILICAL ARTERY • Assoc with other diseases like CHD, neurologic disease, genito urinary diseases, GI malformations • ASPIRATION PNEUMONIA

ATRESIAS AND FISTULAS

ESOPHAGEAL WEBS • Ledge like mucosal protrusions into esophageal lumen • Semi circumferential • Eccentric • Upper esophagus common • Can present as a cause of dysphagia

ESOPHAGEAL WEB

ESOPHAGEAL WEB

ESOPHAGEAL WEB

CAUSES • • • • •

Congenital Long standing reflux esophagitis Chronic GVHD Blistering skin diseases IRON DEFICIENCY ANEMIA

ESOPHAGEAL WEBS • Iron deficiency anemia + glossitis + cheilosis + post cricoid esophageal webs = PLUMMER VINSON SYNDROME / PATERSON BROWN KELLY SYNDROME / SIDEROPENIC DYSPHAGIA • INCREASED RISK OF POST CRICOID ESOPHAGEAL CARCINOMA

ESOPHAGEAL RINGS • Concentric plate of tissue • Distal esophagus • TYPE A RING : above the squamo columnar junction • TYPE B RING / SCHATZKI RING : at the squamo columnar junction

ESOPHAGEAL STENOSIS • Fibrous thickening of the esophageal wall • Atrophy of muscularis propria • Thin or ulcerated epithelium • Causes : 5. Congenital 6. Inflammatory scarring - gastro esophageal reflux - radiation - scleroderma - caustic injury . Progressive dysphagia – initially to solids

LESIONS ASSOCIATED WITH MOTOR DYSFUNCTION 1. ACHALASIA 2. HIATAL HERNIA 3. MALLORY WEISS TEAR

ACHALASIA Failure to relax 3 major abnormalities Aperistalsis Partial / incomplete relaxation of LES with swallowing - Increased resting tone of LES Two types : primary and secondary • • -

Primary achalasia • Dysfunction of inhibitory neurons • Degenerative changes in neural innervation – intrinsic / extrinsic

Secondary achalasia • Chagas disease – trypanosoma cruzi • Polio • Surgical ablation of dorsal motor nuclei • Autonomic neuropathy • Malignancy • Amyloidosis • Sarcoidosis

Morphology • Progressive dilation of esophagus above LES • Wall – normal / thick / thin • Absent myenteric ganglia in body

Clinical features Progressive dysphagia Nocturnal regurgitation Aspiration pneumonia Hazard of developing squamous cell carcinoma • Esophageal candidiasis • Lower esophageal diverticulae formation • • • •

HIATAL HERNIA • Separation of the diaphragmatic crura • Widening of the space between the muscular crura and esophageal wall • Two anatomical types 4. Axial – sliding hernia 5. Non axial – paraesophageal hiatal hernia

ESOPHAGEAL HERNIA

HIATUS HERNIA

HIATUS HERNIA ENDOSCOPY

Cause • Congenital • Acquired

Clinical features • Heartburn • Regurgitation of gastric juices in the mouth when lying down or bending forward • Obesity

Complications • • • • • •

Ulceration Bleeding Perforation Strangulation Obstruction Reflux esophagitis

DIVERTICULAE • Outpouching of the alimentary tract that contains ALL the visceral layers • False diverticulum – only mucosa and sub mucosa • There are 3 types of esophageal diverticulae 4. ZENKER DIVERTICULUM – PHARYNGO ESOPHAGEAL DIVERTICULUM – UES 5. TRACTION DIVERTICULUM – MID ESOPHAGUS

ZENKER DIVERTICULUM • Disordered cricopharyngeal motor dysfunction • With or without GERD • Diminished luminal size of UES

ESOPHAGEAL DIVERTICULAE

ESOPHAGEAL DIVERTICULAE

TRACTION DIVERTICULUM • Scarring – post TB mediastinal lymphadenitis • Motor dysfunction • Congenital lesion

ESOPHAGEAL DIVERTICULAE

ESOPHAGEAL DIVERTICULAE

ESOPHAGEAL DIVERTICULAE

Clinical features • Accumulation of food in the diverticulum • Dysphagia • Food regurgitation • Neck mass • Aspiration pneumonia • Nocturnal regurgitation

MALLORY WEISS SYNDROME Longitudinal tear in the esophagus At the gastro esophageal junction Most common in alcoholics Due to severe retching / vomiting NO REFLEX RELAXATION OF THE LES WITH THE ANTI PERISTALTIC WAVE OF RETCHING / VOMITING • Underlying hiatal hernia can be a predisposing factor • • • • •

MORPHOLOGY • • • •

Linear irregular lacerations In the axis of the esophageal lumen Range in length from mm to cm Tear may involve partial thickness of wall / full thickness - perforation

MALLORY WEISS SYNDROME

MALLORY WEISS TEAR ENDOSCOPY

CLINICAL FEATURES • Sudden upper GI bleed • Mild bleed / massive hemetemesis • Heals with minimal or no residual involvement • Perforation = BOERHAAVE SYNDROME

ESOPHAGEAL VARICES • Dilated tortuous esophageal sub epithelial and sub mucosal veins is called as esophageal varices • Causes : any cause of portal hypertension 3. Alcoholic cirrhosis most common cause. 4. Cirrhosis of other etiology also manifest as varices

PORTAL HYPERTENSION DIVERSION OF PORTAL BLOOD FLOW CORONARY VEINS OF STOMACH ESOPHAGEAL SUB EPITHELIAL AND SUB MUCOSAL VEINS

AZYGOS VEINS SYSTEMIC CIRCULATION

MORPHOLOGY • Dilated tortuous veins • Distal esophagus and proximal stomach • Sub mucosal and sub epithelial channels massively dilated • Mucosa irregularly protruding into the lumen • Mucosa normal / eroded and inflamed • Rupture – massive hemorrhage into the lumen and hemorrhage into the wall of the esophagus

ESOPHAGEAL VARICES

ESOPHAGEAL VARICES

ESOPHAGEAL VARICES

ESOPHAGEAL VARICES

ESOPHAGEAL VARICES

ESOPHAGEAL VARICES

CLINICAL FEATURES • Asymptomatic / massive hemetemesis • Death due to massive bleed / hepatic coma triggered by hemorrhage

ESOPHAGITIS • • • • • • • • • • • • • •

GERD / REFLUX MUCOSAL IRRITANTS – alcohol, corrosive acids, alkalis, excessive hot fluids like tea, heavy smoking CYTOTOXIC ANTI CANCER THERAPY BACTERIA HSV VIRUS CMV VIRUS FUNGAL : immunosuppressed – candida, aspergillus, mucor mycosis UREMIA RADIATION GVHD AUTO IMMUNE DISEASES PEMPHIGOID AND BULLOUS DISORDERS OF SKIN CROHN DISEASE DRUGS

GASTRO ESOPHAGEAL REFLUX DISEASE (GERD) OR REFLUX • Reflux of gastric contents into lower esophagus most important cause • Reduced LES tone / decreased efficiency of anti reflux mechanisms - CNS depressants - Hypothyroidism - Pregnancy - Systemic sclerosing disorders - Tobacco exposure - Nasogastric tube

GERD • Hiatal hernia – especially sliding • Inadequate / slow clearance of refluxed material • Delayed gastric emptying • Increased gastric volume • Reduced reparative capacity of esophageal mucosa by protracted exposure to gastric juices • Gastric juices +/- bile from duodenum

MORPHOLOGY • Inflamed esophagus – “redness” • Inflammatory cells in the epithelial layer – eosinophils, neutrophils, lymphocytes • Basal zone hyperplasia • Capillary congestion in lamina propria with elongation of papillae

CLINICAL FEATURES • • • • • •

Dysphagia Heartburn Regurgitation of sour material Hemetemesis Melena Chest pain

CONSEQUENCES • • • •

Bleeding Ulceration Stricture formation Barrett esophagus formation

BARRETT ESOPHAGUS • It is the metaplastic change occurring in the distal esophageal epithelium where in the squamous epithelium is replaced by metaplastic columnar epithelium. • GERD IS THE SINGLE MOST IMPORTANT CAUSE • BARRETT ESOPHAGUS IS THE SINGLE MOST IMPORTANT RISK FACTOR FOR

CRITERIA 1. Endoscopic evidence of columnar epithelial lining above the gastro esophageal junction 2. Histologic evidence of intestinal metaplasia in the biopsy specimens from the columnar epithelium

CLASSIFICATION 1. SHORT SEGMENT < 3cm cephalad 2. LONG SEGMENT > 3cm cephalad from the manometric gastro esophageal junction

ENDOSCOPIC VIEW OF ESOPHAGEO GASTRIC

BARRETT ESOPHAGUS

BARRETT ESOPHAGUS

BARRETT ESOPHAGUS

BARRETT ESOPHAGUS

NORMAL GASTRO ESOPHAGEAL JUNCTION

HISTOLOGY • Definitive diagnosis is made when the squamous epithelium is replaced by columnar mucosa • Also the columnar mucosa contains intestinal goblet cells • Low or high grade dysplasia can be present

BARRETT ESOPHAGUS

BARRETT ESOPHAGUSDYSPLASIA

TUMORS OF ESOPHAGUS • BENIGN: 2. EPITHELIAL - Squamous cell papilloma - Adenoma 2. MESENCHYMAL - Leiomyoma - lipoma

Tumors • MALIGNANT 1. EPITHELIAL: - Squamous cell carcinoma - Adenocarcinoma 2. MESENCHYMAL - leiomyosarcoma

CARCINOMA ESOPHAGUS • • • • • •

Usually diagnosed late Aggressive spread Men > 50 years of age Varied incidence world wide Chinese and japanese common Bad prognosis

RISK FACTORS FOR CA ESOPHAGUS 1. -

ESOPHAGEAL DISORDERS: Long standing eophagitis Barrett esophagus Achalasia Hiatus hernia Diverticula Plummer Vinson syndrome

2. DIET AND LIFE STYLE - Smoking - Alcoholism - Deficiency of vitamins A,C, riboflavin, thiamine, pyridoxine - Trace element deficiency – zinc, molybdenum - Fungal contamination of food stuff - High content of nitrites /

3. GENETIC FACTORS: - Tylosis : hyperkeratosis of palms and soles - Inherited defects of cancer

MORPHOLOGY • Squamous cell carcinoma and adenocarcinoma are the 2 common types • SCC comprises almost 90% of cases • Elderly men • Most common in mid esophagus – 50% lower esophagus – 30% upper esophagus – 20%

PRECURSOR • DYSPLASIA CARCINOMA IN SITU INVASIVE CANCER • BARRETT ESOPHAGUS LOW GRADE DYSPLASIA HIGH GRADE DYSPLASIA INVASIVE ADENOCARCINOMA

SCC 1. Polypoid fungating type 2. Ulcerating type 3. Diffuse infiltrative type MICRO : well differentiated to poorly differentiated squamous cell carcinoma

ADENO CARCINOMA • Usually arises in a setting of Barrett esophagus • Lower and mid esophagus common sites • Nodular, elevated masses in lower esophagus MICRO : Most of them are well differentiated mucin producing tumors

CLINICAL FEATURES • • • • • • •

Weight loss Anorexia Fatigue Weakness Pain during swallowing Dysphagia Spreads very soon because of the extensive lymphatic network

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS

SQUAMOUS CELL CARCINOMA ESOPHAGUS

CARCINOMA ESOPHAGUS STAGING