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OESOPHAGUS AND

STOMACH
Lecture Outline
Oesophagus
Premalignant non-neoplastic disorders
Neoplasms
Causes of upper GI Haemorrhage

Stomach
Inflammatory disorders
Neoplasms
Oesophagus
Congenital Abnormalities
Plummer - Vinson Syndrome
(Paterson - Kelly)
Webs
Fe deficiency anaemia
Atrophic glossitis
risk of malignancy

Oesophagus
Achalasia Cardia
Decreased/loss of myenteric ganglion cells
Aperistalsis
resting tone LES
Dilatation
Stasis
Inflammation
Neoplasia (5%)
Oesophagitis
Reflux
Bleeding
Ulceration
Stricture
LES tone, alcohol, pregnancy, CNS
depression, obesity
Columnar metaplasia (Barretts)
10% risk of malignancy
Infectious
Candida- AIDS

Oesophageal Varices
Porto-systemic anastomosis
Cirrhosis
Bud-Chiari syndrome
Hepatic vein thrombosis
Portal vein thrombosis
Veno-occlusive disease (VOD)
Complication
Rupture- <50% of UGI bleed
Cause of death of 50% of
alcoholics
Mallory-Weiss Syndrome
Longitudinal tears at GEJ
Partial or complete thickness
Severe retching
Alcoholic
5-10% of UGI bleed
Oesophageal Tumour
Benign
Leiomyomas

Malignant
Squamous cell carcinoma (90%)
Adenocarcinoma (10%)
Oesophageal Carcinoma
6% of GIT cancers
SCC
>50 M:F= 2:1 B>W
Dietary factors
Vitamin deficiencies
Zn deficiency
Nitrites/nitroamines
Lifestyle
Cigarette
Alcohol


Oesophageal Carcinoma
Location (SCC)
Middle1/3 -50%
Lower 1/3 30%
Upper 1/3 20%

Morphology
Polypoid/exophytic 60%
Excavating 25%
Flat 15%

Oesophageal Carcinoma
Adenocarcinoma
Barretts metaplasia*
Submucosal glands

Microscopy
SCC - keratin
Adeno glands mucin
Stomach
Gastritis
Acute
Chronic
Acute
Superficial acute inflammation
haemorrhage
polymorphs
superficial erosion
Acute Gastritis
Pathogenesis
acid secretion
HCO
3
-
blood flow
mucosal barrier
Acute Gastritis
Aetiology
NSAID/Aspirin
Alcohol
Smoking
ChemoRx drugs
Uremia


Stress
Trauma
Burns Curlings
Head injury Cushings
Surgery
Shock
Ischaemia
Sepsis

Acute Gastritis
Clinical Features
Asymptomatic
Pain
Nausea/vomiting
Haematemesis
Melaema
Chronic Gastritis
Aetiology
Helicobacter pylori (90%)

Autoimmune (<10%)
Pernicious anaemia

Toxins - ETOH, Smoking

Bile Reflux (post-gastrectomy)

Chronic Gastritis
Morphology
Autoimmune (type A)
Diffuse, body and fundus
More severe
Atrophy, auto-antibodies & parietal cell loss
H. pylori-associated (type B)
Focal or diffuse, antral and body
Polymorph infiltration
Lymphoid nodule formation
Chronic Gastritis
Chronic mucosal inflammation
Superficial or deep
mucosal atrophy
intestinal metaplasia
No erosion
Gastric Tumours
Benign
Leiomyomas
Adenomas


Malignant
Adenocarcinoma (>90%)
Lymphomas (4%)
Endocrine cell tumours (3%)
Stromal tumours (2%)
Gastric Carcinoma
M:F =2:1
Japan, Chile, Costa Rica
Predisposing factors
Environmental factors
Diet
preserved/smoked/salted foods
fresh fruits and vegetables
Low socioeconomic status
Cigarette smoking
Gastric Carcinoma
Host factors
CGIM H pylori
Partial gastrectomy
Adenomas
Genetic factors
Bld grp A
Family Hx
Lynch syndrome (HNPCC)

Gastric Carcinoma
Classification
Depth of invasion
Early (95% 5YS)
mucosal & submucosal LN
Advanced (<15% 5YS)
Morphology
Exophytic
Flat (linitis plastica)
Excavated
Gastric Carcinoma
Classification
Histologic Types (Lauren Classification)
Intestinal
CGIM H pylori
M:F =2:1, 55y
Diffuse
Spontaneous
M:F =1:1, 48y
GIT Mesenchymal Tumours
Differentiation
Stromal Tumours
(GIST)
Smooth Muscle
(Leiomyosarcoma)
Neurogenic

Causes of Upper GI Haemorrhage
Specific
Oesophageal Gastric
Varices Acute Gastritis
Mallory Weiss Ulcers
Neoplasia
Duodenal
Ulcers
Non-specific


SMALL INTESTINE AND
APPENDIX
Lecture Outline
Small Bowel
Peptic ulcer disease
Causes and mechanisms of diarrhoea
Clinicopathologic features of Crohns disease
Neoplasms
Appendix
Appendicitis
Neoplasms and Multiple Endocrine
Adenopathy syndrome



Peptic Ulcer
Area of acid/pepsin digestion
Relative or absolute acidity

Acid Secretion vs Mucosal Barrier

Peptic Ulcer
Area of acid/pepsin digestion
Duodenum (70-75%)
Antrum (20-25%)
GEJ
Multiple ZE
Meckels diverticulum
Relative or absolute acidity vs mucosal
barrier

Peptic Ulcer
Aetiology
M>F DU =3:1 GU =2:1
H. Pylori
DU - 95%
GU 70%
NSAIDs (GU)
Zollinger - Ellison Syndrome
Other
Peptic Ulcer
Morphology
<4cm
Round/oval, punched out margins
Clean base
GU
Lesser curve, antrum
Radiating rugal fold
DU
1
st
part
Peptic Ulcer
Histology
Fibrin and necrotic debris
Non-specific inflammation
Granulation tissue
Scar tissue (fibrosis)
Peptic Ulcer
Complication
Bleeding
Perforation
Obstruction
Intractable pain
? Malignant change
GU - <1%
DU - never
Enterocolitis
Diarrhoea
mass, frequency and fluidity

Dysentery
Painful, bloody diarrhoea
( +low volume )
Diarrhoeal Disorders
Secretory
Osmotic
Exudative*
Deranged Motility
Malabsorption*
Infectious Enterocolitis
Viruses
Rota - Infants
Norwalk - Child., Adults
Adeno
Damaged mature enterocytes are
replaced by immature secretory cells =>
secretory and osmotic diarrhoea.

Bacterial Enterocolitis
Preformed Toxins
S. aureus, Vidrios,
C. perfringens

Enterotoxins
E. coli, V. cholerae

Enteroinvasive
Salmonella, Shigella,
C. jejuni, Yersinia
Parasitic Enterocolitis
Protozoa
Giardia
Cryptosporidia

Helminths
Strongyloides
Ascaris
Hookworm
Malabsorption
Definition

Sub-optimal absorption of fat, fat-soluble
and other vitamins, protein,
carbohydrate, electrolytes, minerals and
water.
Malabsorption Syndrome
Symptoms
Diarrhoea - Bulky, Frothy, Greasy
Weight Loss
Abdominal Distention
Borborygmi
Malabsorption
Consequences
GIT - Diarrhoea
Blood - Anaemia ( Fe, B12, Folate )
- Bleeding
Musculoskeletal - Osteopenia, Tetany
(Ca, Mg, Vit D, Protein )
Endocrine
Skin
Nervous System
Malabsorption
Common Causes
USA - celiac sprue
- chronic pancreatitis
- crohns disease

Ja - chronic pancreatitis

Unusual Causes
Celiac disease (Gluten-sensitive enteropathy,
Nontropical sprue)
Rare in nonwhites

Tropical Sprue (Post-infectious Sprue)
Caribbean (not Ja), South and Central America

Whipples Disease
Whites 30 - 40 yrs
GIT AND HIV
Malabsorption

Infection
cryptosporidia shigella
isospora CMV
salmonella HSV


Crohns Disease
(Terminal ileitis, Regional enteritis)

Inflammatory Bowel Disease
Chronic relapsing
Granulomatous
Unknown aetiology
Crohns Disease
Mouth to anus
Genetic determinants: HLA-B27
? infectious ? immune mediated
Any age peaks 50 - 60
F > M white = 2 - 5x nonwhites
Jews 2 - 5x non-Jews
Crohns Disease
Transmural inflammation
Segmental
Noncaseating granulomas 50%
Fissures and fistulas
Mural fibrosis and strictures
Creeping fat
Lymphadenopathy
Systemic manifestations
IBD Extra-GI Manifestations
Migratory polyarthritis

Sacroiliitis

Ankylosing spondylitis

Erythema nodosum

Clubbing
Small Intestine Tumours
3 - 6 % of GIT tumours
Benign
Leiomyomas
Adenomas
Lipomas
Malignant
Adenocarcinomas
Endocrine cell tumours
Lymphomas
Stromal tumours

Endocrine Cell Tumours
(Carcinoids)

Slow growing

Low malignant potential
benign - appendix, rectum
malignant - ileum, stomach, colon
Hamartomatous Polyps
Peutz Jegher/ Syndrome
muscularis mucosa

Juvenile/ Syndrome
lamina propria
(colon)
APPENDIX
Acute Appendicitis
Luminal obstruction
(fecolith, tumour, worms)

Increased intraluminal pressure

Mucosal ischaemia

2
o
bacterial colonization
Acute Appendicitis

Morphology
suppurative
gangrenous
empyema

Complications
abscess
perforation
peritonitis
septicaemia
mucocele
Acute Appendicitis
DD
Mesenteric adenitis ( yersinia, virus )

Acute salpingitis

Ectopic gestation

Mittelschmerz

Meckels diverticulitis
Appendix Tumours
Mucinous cystadenoma/ carcinoma
- pseudomyxoma peritonei

ECT - carcinoid

Adenocarcinoma
Multiple Endocrine Adenopathy
(Neoplasia)
Hyperplasia and neoplasia of more than
one endocrine gland

Autosomal dominant ( some recessive )

3 syndromes
MEA
I
pituitary
parathyroid
pancreas
adrenal
PUD
II
pheo
medullary ca
III
pheo
medullary ca
ganglioneuro
osteoma