Pathology of Oesophageal disorders

Normal Anatomy
• Extends from Pharynx (C6) to Gastro oesophageal junction (T11/T12).

• 25.0 cm in length.

• 3 points of narrowing. Cricoid cartilage.

L/S Bronchus. Diaphragm.

• UES – 3cm segment at the cricopharyngeal muscle.

• LES – 2 – 4 cm segment in the abdomen proximal to the anatomical GE sphincter.

Histology.
• Mucosa – non keratinizing squamous epithelium.

• Submucosa – loose Connective tissue.

• Muscularis propria .

– Inner – circular.

– Outer – Longitudinal.

Skeletal mm fibres in the initial 10 – 12 cms. (Cricopharngeus)

• Serosal Coat - ABSENT .

Oesophageal disorders.
• Congenital abnormalities.

• Motility disorders.

– Achalasia cardia.

– Oesophageal diverticula.

– Rings and webs.

• Ulcerations and lacerations.

• Vascular lesions.

• Organic lesions.

– Strictures and tumours.

Congenital abnormalities.

• Stenosis .

• Atresia .

• Heterotopia – Gastric mucosa. Sebaceous

glands.

• Cysts – Inclusion cyst.

– Columnnar and squamous epithelial lined cysts.

Retention cysts. .

Motility disorders.

• Achalasia cardia.

• Diverticula .

• Rings and webs.

• Hiatus hernia *.

Gastro oesophageal reflux disease.

Diverticula --Outpouchings of the the mucosa at points of weakness.

TRACTION DIVERTICULUM-Epiphrenic – above the diagphragm .

Zenkers – Pharyngo oesophageal .

PULSION DIVERTICULUM -Pull due to attachement to extrinsic structures .

Eg: TB Lymph nodes.

• MULTIPLE – Diffuse intramural oesophageal diverticulosis.

• COMPLICATIONS – Obstruction, infection, haemorrhage, perforation, increased incidence of

malignancy.
Rings & Webs
Above the aortic arch

(Upper oesophagus).

PLUMMER VINSON SYNDROME.

Female > Male.

Fe deficiency anaemia.

Glossitis.

Lower Oesophageal .

(Schatzki & Rings) .

Achalasia cardia.
• Failure of the cardia (LES) to open when the peristaltic wave reaches it.

• Major abnormalities in the Achalasia cardia Aperistalsis.

Partial / complete relaxation of LES .

Increased basal tone of LES.

• Symptoms – Progressive dysphagia .Regurgitation of undigested food.

Aspiration pneumonia. Retrosternal discomfort. Foetid flatulence.

• Pathology-Progressive dilatation of the upper segment.

• Wall -thickened proximally due to muscular hypertrophy.
-Wall thinned out due to dilatation.
-Normal in thickness.
• Ganglia – absent in upper segment.
• Ulceration and inflammation of the oesophageal lining.
Hiatus Hernia.
• Sliding type – Disturbance of the normal relationship of the gastro oesophageal
junction. Reflux.

Paraoesophageal / sliding type – Strangulation & Obstruction.

Ulceration of the Oesophagus.

• Mallory – Weiss Syndrome – ( laceration / tear)

• Oesophagitis.

Mallory – Weiss Syndrome

Tear in the oesophageal mucosa which is oriented longitudinally astride the oesophagogastric
junction: Common in alcoholics.

Inflammations – Oesophagitis.
• Reflux oesophagitis.

• Prolonged gastric intubation.

• Ingestion of corrosive alkali, smoking.

• Uraemia.

• Bacteraemia / Viraemia. – HSV CMV,

• Fungal infection – Candida, Mucor, Aspergillus.

• Cytotoxic treatment.

• Pemphigoid and Epidermolysis Bullosa.

• Graft vs Host disease.

Relux oesophagitis (GERD/GORD)
• Reflux of gastric contents.

• Inflammatory changes are due to.

– Frequent protracted reflux - ? Incompentance of the LES.

– Disordered oesophageal motility – contact of gastric contents with the

oesophagus for longer periods.

– Elevated acid peptic levels in the gastric fluid..

Inflammation and ulceration of the squamous epithelial lining.

Prolonged reflux of gastric contents.

Healing of the lining by formation of intestinal or gastric type epithelium – metaplasia.

This epithelium is better able to withstand the effects of the gastric juices.

Barrett’s Oesophagus.
• Congenital / Acqiured (Reflux induced).

• Metaplasia of the oesophageal mucosa..

• Predisposition to Adenocarcinoma..

Vascular lesions – Varices..

• Dilatation of oesophageal submucosal veins due to portal hypertension.

• Lower 3rd of the oesophguse .

• Presents with haematemsis .

Strictures of the oesophagus
• Congenital.

• Reflux disease induced strictures.

• Corrosive poisoning.

• Tumors.

• Rare – Scleroderma.

Oesophageal Tumors..
Benign- Leiomyoma .

Malignant- Squamous Carcinoma 85%.

Adenocarcinoma 15% .

Oesophageal Carcinoma.

• Adults > 50 years.

• M:F = 4:1.

• Geographical distribution - North China, Iran, USSR, S. Africa.

Squamous Carcinoma Predisposing factors.

– 1. Dietary - fungal contamination, High content of nitrites / nitrosamines, def of
Vit & trace metals..

– 2. Oesophageal disorders - Achalasia cardia, Diverticula, Oesophageal stasis..

– 3. Life style - Alcohol, Tobacco..

– 4, Genetic - Epidermolysis Bullosa, Coeliac disease, Ectodermal dysplasia..

Clinical features.
• PROGRESSIVE DYSPHAGIA UNTIL PROVED OTHERWISE IS CARCINOMA OESOPHAGUS..

• Regurgitation…

• Pain..

• Loss of weight - BUT NOT LOSS OF APPETITE…

Morphology..
• Site - Commonest in the middle 3rd…

• Macroscopy …

– 1. Polypoidal fungating. ) 15%..

– 2. Nodular mass. )

– 3. Diffuse infiltrative - flat lesion.

– 4. Excavated /ulcerated..

– Superficial (in -situ)..

Microscopy…
• Squamous carcinoma…

– Cell keratinization ..

– Intercellular bridges /prickles…

– Keratin pearls..

Metastases…
• Blood stream spread is uncommon. - Lung Brain & Bone..

• Lymph node - ..

– Upper 3rd - Cervical..

– Middle 3rd - Mediastinal, tracheobronchial, paratracheal..

– Lower 3rd - Gastric & Coeliac node..

Causes of Death..

• Starvation & wasting..

• Tracheo-oesophageal fistula - Aspiration pneumonia..

• Rupture - Mediastinitis..

• Haemorrhage ..

• Distant spread..

Presentations of oesophageal disorders – Symptoms..

– Dysphagia – Difficulty in swallowing..

• Organic disease (stricture and carcinoma)..

• Motilitiy disorders –Dysphagia for liquids more likely..

– Regurgitation..

– Odynophagia – localized pain associated with swallowing..

– Pain ..

• Heart burn – due to reflux..

• Angina like tightening chest pain – occur in association with meals..

– Waterbrash – mouth being full of fluid which is salty in taste..

Presentations of oesophageal disorders – Atypical symptoms..

 • Anaemia ..

• Pulmonary symptoms – due to aspiration pneumonia in reflux..

– Coughing ..

– Choking..

– Repeated chest infections..

Presentations of oesophageal disorders – Physical signs..

• Weight loss..

• Pallor..

• Neck swellings – pharyngeal pouch, enlarged lymph nodes..

• Chest signs on auscultation..

• Epigastric mass – carcinoma of cardia enlarging down..

• Others – Tylosis, koilonychia..