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5/14/2017 PGIN3-3 Pathology of Upper GI Disorders

BasicPathologyTutorialYear3

Head&Neck,UpperGastrointestinalDiseases

GrossSpecimensfordescriptionbystudents:

HeadandNeck:

Lab1 CU341(10A2)
Lab2 CU674(10A2)
Lab3 CU857(10A2)
Lab4 CU1200(10A2)
Lab5 CU1545(10A2)
Lab6 CU1783(10A2)

Gastritis,gastriculcersandduodenalulcers

Lab1 CU316
Lab2 CU195
Lab3 CU448
Lab4 CU1471
Lab5 CU1479
Lab6 CU1491

Tumoursofthestomach

Lab1 CU170
Lab2 CU317
Lab3 CU677
Lab4 CU1186
Lab5 CU1191
Lab6 CU2211

Tumoursoftheoesophagus

Lab1 CU900
Lab2 CU1057
Lab3 CU1059
Lab4 CU1060
Lab5 CU1061
Lab6 CU1062

Microscopicslidesfordescriptionbystudents:

TT145Chronicpepticulcer

TT144Carcinomaofthestomach

TT129Carcinomaoftheesophagus

Demonstrationslides:

TT140Normalstomach
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TT141Normalpylorus

TT130Carcinomaofthestomach

TT142Carcinomaofthestomach

TT143Carcinomaofthestomach,diffusetype(linitisplasticatype)

Squamouscellcarcinomaisthemostcommonmalignantneoplasminlarynx.Thetumorcanbe
furthersubdividedbytheanatomicallocationsinthelarynxwithreferencetovocalcord:supraglottic
(abovevocalcord),glottic(involvingvocalcord)andsubglottic(belowvocalcord).Thosetumors
involvingalltheregionsaboveandbelowvocalcordarecalled"transglottic".Laryngealtumorsof
differentsublocationshaveslightvariationsinthecriteriaoftumorstaging,whichisoneofthe
importantprognosticindicators.

CU341:Thisspecimenconsistsofanopenedlaryngectomyspecimenwithamalignantirregular
exophytictumorgrowthintheleftsideofthesubglotticregion.Thethyroidcartilageappearsnot
involved.

CU674:Anopenedlaryngectomyspecimenwithanulcerativetumorintheleftsupraglotticregion.

CU857:Anexophytictrasglotticlaryngealtumorinvolvingbothsidesofthelarynx.

CU1200:Anexophytictumorintheleftsupraglotticregionofthelarynx.

CU1545:Atransverselycutlyarynectomyspecimen,containinganexophytictrasglotticlaryngeal
tumorinvolvingbothsidesofthelarynx.

CU1783:Anulcerativetransglotticlyaryngealtumor.(Themultiplecutsarecausedbysamplingfor
diagnosisbypathologist.)

Goalsforthestudentsatthislaboratorysession:

Tobeabletoidentifyanddescribethegrossfeaturesofesophagealandgastrictumours
Tobeabletodescribefeaturesofacuteandchronicgastritis.
Tobeabletodiscussthemicroscopicfeaturesofpepticulcer.
Tobeabletodifferentiatethemicroscopicfeaturesofearlyandlategastriccancers.

Goalsforthestudentsatthistutorialsession:

1.Toknowthecommonnonneoplasticandneoplasticlesionsoftheesophagusandstomach.

2.Toknowthepathogenesisofesophagitis.

3.Toknowthepathogenesisofgastritis,pepticulcerdisease,pyloricstenosisandcancerofthe
stomach.
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PGIN33PathologyofUpperGIDisorders

Goalsforthestudentsatthislaboratorysession:

1.Tobeabletoidentifyanddescribethegrossfeaturesofesophagealandgastrictumours
2.Tobeabletodescribefeaturesofacuteandchronicgastritis.
3.Tobeabletodiscussthemicroscopicfeaturesofpepticulcer.
4.Tobeabletodifferentiatethemicroscopicfeaturesofearlyandlategastriccancers.

Goalsforthestudentsatthistutorialsession:

1.Toknowthecommonnonneoplasticandneoplasticlesionsoftheesophagusandstomach.
2.Toknowthepathogenesisofesophagitis.
3.To know the pathogenesis of gastritis, peptic ulcer disease, pyloric stenosis and cancer of the
stomach.

Gastritis,gastriculcersandduodenalulcers

Benign peptic ulcers are mostly located in the pyloric antrum, lesser curve and the first part of
duodenum.Mostulcersaresolitary(80%)andsmall(50%<2cm,75%<3cm,10%>4cm).Size
does not predict a malignant ulcer, although smaller ulcers tend to be benign. Benign ulcers are
roundtooval shaped with sharppunched out edges. The mucosal margin overhangs the base. A
bleeding vessel may be found at the base. Some fibrosis may be due to repeated healing and
ulcerativeprocesses.

CU316

lesser curve

tumour
edge is sharply demarcated

greater curve

Ulcerattheantrum.Thespecimenconsistsofpartofthebodyandtheantrum.Alargeulcerisnoted
atthebodyantralregion.Thebaseoftheulcerisfairlysmooth.

CU195

http://webapps.acp.cuhk.edu.hk/med3/upper_gi.html 3/22
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less gastric folds


in stomach antrum

blood clot

Ulcerattheantrum.Thisspecimenconsistsoftheantrumandthebodyofthestomach.Anulceris
seen at the antrum. The base of the ulcer is smooth. Blood clot at the base indicates previous
bleeding.

CU448 fibrotic changes are white


can be seen in base of tumour

Ulceratthelessercurveneartheangularincisure.Thisspecimenconsistsalargepartofthebodyof
the stomach. A large ulcer is noted at the lesser curve near the angular incisure. The base of the
ulcerissmooth.Ableedingvesselisfoundatthebase.Fibrosisisseenfromtheserosalsurface.
hence the black hole in the tumour

CU1471

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perforated duodenal ulcer

Ulcerattheduodenum.Thespecimenconsistsofthestomachandtheduodenum.Theulcerissmall.
Perforationmightoccurandisanimportantdifferentialdiagnosisofacuteabdomen.

CU1479

Ulceratthestomach.Thespecimenshowsthebodyofthestomachwithsmallulcer.Thebaseofthe
ulcer is smooth. The rugae are drawn towards the ulcer. Regeneration of the mucosa results in a
slightlyoverhangingappearances.
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CU1491

yellow part: blood / blood clot


hole is by surgical incision due to clean cut
greater
curve

Ulcer at the lesser curve near the angular incisure. This specimen consists of the oesophagus ,
stomachandduodenumwithanulceratthelessercurveneartheangularincisure.Bloodclotatthe
baseindicatespreviousbleeding.

Tumoursofthestomach

Malignantprimarygastrictumorsaremostlyadenocarcinoma.Grossly,gastriccarcinomaspresentas
:a)afungatingorpolypoidmassb)malignantulcerwithraisedevertededgesc)anexcavatedulcer
resembling chronic peptic ulcer or d) as a diffusely infiltrating lesion that causes thickening and
contraction of the stomach wall with relatively little mucosal involvement. Gastric carcinomas are
frequentlyatpylorusandantrum(50to60%),cardiac(2025%),lessercurvature(40%)andgreater
curvature(1215%).Therefore,thefavouredlocationofgastriccarcinomaisonthelessercurvature
ofantropyloricregion.

CU170

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Tumour at the lesser curve. The specimen shows a stomach opened on the greater curve with a
malignant ulcer on the lesser curve. This tumour disrupts the normal rugal pattern of the gastric
mucosaandinfiltratesthestomachwall,involvingtheserosa. note the white lines

CU317

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Tumour at the antrum. The specimen shows the lower part of the body with the antrum. The
specimen is opened on the greater curve. A malignant ulcer is seen in the antrum. This tumour
infiltratesthestomachwall,involvingtheserosa.

CU677

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Tumouratthelessercurve.Thespecimenconsistsofpartofastomachopenedonthelessercurve.
Alargepolypisnotednearthegreatercurveonthebody.Thislargepolypoidmassprotrudesoutinto
thecavityofthestomach.Themucosalsurfaceisulcerative.Itinfiltratesthestomachwall.
(its not smooth)

CU1186

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Tumouratthepyloricantrum.Thespecimenconsistsofpartofthebodyandtheantrum.Thistumour
islarge,occupyingnearlythewholeantrum.Itinfiltratesthestomachwallinvolvingtheserosa.Blood
ontheulcerativesurfaceindicatesprobablychronicbleedingfromthetumour.

CU1191

Tumour in the stomach. The specimen consists of the body and the antrum of the stomach. This
tumourexpandsthesubmucosaandinvolvescircumferentiallyatthebodytotheantrum.Thetumour
infiltratesthestomachwall.

CU2211

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tumour has infiltrated into the wall


> no more stomach ruggae

mucin collects in wall /


submucosal area

Tumour in the stomach. This specimen consists of the body of the stomach opened on the greater
curve.Thistumourislocatedmainlyatthelessercurve.Itappearsinfiltratingthestomachwalland
involving the serosa. Cystic spaces represent collections of mucin. The normal rugal pattern of the
gastricmucosaislost,indicatingdiffuseinfiltrationofthetumour.

Tumoursoftheoesophagus

Carcinomas, especially squamous cell carcinomas of the oesophagus represent vast majority of
malignant oesophagus tumours. The tumours could be classified according to their cell types.
Squamouscellcarcinomasconstitute8085%ofallOesophagealcarcinomasandadenocarcinomas
makeupabout5to15%andtheremaindercomposeofundifferentiatedorrarecancers.Over50%of
carcinomasoftheoesophagusariseinthemiddlethird,39%inthelowerthirdand20%intheupper
third. Generally, three gross morphologic patterns can be recognised in carcinomas of the
oesophagus.Themostcommononeisthatofthepolypoidfungatinglesion(60%)thatprotrudesinto
thelumen.Thesecondgrosspatternisnecroticcancerousulceration(25%)thattendstoexcavate
deep into the surrounding structure. The third type is the diffuse infiltrating pattern that tends to
spread within the wall of the oesophagus. In the fungating tumour, the lesions are raised and
protruded into the lumen. In most of the times, the lesions have infiltrated deep into the muscular
layers.

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CU900

ulcerative tumour that


involves the wall
spreading along the mucosa

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Thisspecimenconsistsofanopenedoesophaguswithamalignantulcer.Thetumourinfiltratesthe
walloftheoesophagus.Mucosalspreadisalsoseen.

CU1057

Thisspecimenconsistsofanopenedoesophaguswithamalignantulcer.Thetumourinfiltratesthe
walloftheoesophagusthroughthemuscularispropria.Mucosalspreadisalsoseen.


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CU1059

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Thisspecimenconsistsofanopenedoesophagusandthecardiaofthestomach.Amalignantulceris
seen.Thetumourinfiltratesthewalloftheoesophagus,disruptingthemuscularispropria.

CU1060

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ulcerative tumour
stenosis / stricture >
difficulty swallowing (dysphagia)

Thisspecimenconsistsofanopenedoesophaguswithacircumferentialmalignantulcer.Thetumour
infiltratesthewalloftheoesophagus.Thetumourresultsinnarrowingoftheoesophagusresultingin
difficultiesinswallowing.

CU1061

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Thisspecimenconsistsofanopenedoesophaguswithamalignantulcer.Thetumourinfiltratesthe
walloftheoesophagus.Mucosalspreadisalsoseen.

CU1062

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Thisspecimenconsistsofanopenedoesophaguswithamalignanttumour.Thetumourispolypoid
andprotrudesintothelumenresultinginobstruction.Itinvolvesthesubmucosaandappearsconfined
withinthewalloftheoesophagus.

Microscopicslides

SlidesTT140&TT141

Identifytheorgan.

Identitythelayerspresentinthisorgan.

Canyouidentifythespecialisedcellsofthisorgan? neutrophils (multi-nucleated)

Trytoappreciatethedifferencesintheglandsbetweentwoslides.

SlideTT129

keratin pearl and intercellular bridge

Identifytheorganonlowpower.

Describethechangesintheepithelium.

Canyouidentifytheinterruptionofthenormalepitheliumbyanewgrowth?

Describethemorphologyofthenewgrowth.

Canyouseeinvasionbythenewgrowthinyoursection?

Whatisthemostreasonablediagnosis? squamous cell carcinoma of oesophagus

Howwouldyougradethistumor?

SlideTT130

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gastric pits
fat cells and tumour glandular cells
advanced stage of adenocarcinoma

Identifytheorgan.

Istheepitheliumnormal?

Canyoudescribethechangesintheepithelium?

Ifyouthinkthisisamalignanttumor,isthereinvasionofthistumorintothemuscularislayer?How
deepistheinvasion?

Whatisyourdiagnosis?

SlideTT144

tumour infiltrated muscularis propria


lots of cystic spaces (compared to previous slide)
secreting mucin (feature of gastric carcinoma)

Identifytheorgan.

ComparethisslidewithslidesTT130andTT142.Canyoudescribethedifferenceinthemorphology
oftheneoplasticcells?

Whatkindofsubstancearethesecellssecreting? mucin

Whatstainwillbemostappropriatetodemonstratethissecretion? mucicarmine (for mucin)

Whatisyourdiagnosis?

SlideTT143

Identifytheorgan. stomach

Describethemorphologyofthegrowth.

Doyouthinkthereareneoplasticcellsinvasiveinthissection? yeah into muscularis propria

Describewhatisdesmoplasticreaction?Isthisfeaturepresentonthisslide?

Whatisyourdiagnosis? diffuse tumour, advanced gastric carcinoma

Whatistheprognosisofthistumor?


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SlideTT145

Identifytheorgan.

Locatetheulceratedareaandidentifythefourdistinctlayersseeninanulcer(refertoyourlecture
notes).
goblet cells
Identifythefociofmetaplasicchange(intestinalmetaplasia)inthissection.

Findthecurverodorganism(Hpylori)onthesurfaceofthemucosa. seagull shape

Observe the degree (mild, moderate or severe) and types of inflammatory cell infiltration on the
mucosa. plasma cells (basophilic), histology characteristics: dotted nuclei around the periphery with perinuclear halo

Namethemaincausesofpepticulcer.

Problemsforstudents:

1.Discusstheriskfactorsforsquamouscellcarcinomaoftheesophagus.
2.Discussthepathogenesisofpepticulcer.
3.Discussthetypesofchronicgastritis.
4.Discusstheriskfactorsandlocationofgastriccancers.
5.Comparethegrossfeaturesofbenignandmalignantgastriculcer.

ListofVocabulary

Dysphagia

Odynophagia

Pyrosis(Heartburn)

Achalasia

Barrett'sesophagus

MalloryWeisssyndrome

Boerhaave'ssyndorme

Varices

Cushing'sulcer

Curling'sulcer

PeutzJegherspolyps

Linitisplastica

Intestinalmetaplasia

Helicobacterpyloriandhelicobactergastritis

Krukenbergtumor

Refluxesophagitis
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