PATHOLOGY

RAJEEV KUMAR, MD

GI SYSTEM
1.

A 45 yr old clerk presented to family physician for heart burn of 7 yr

duration. He has been intermittently taking prilosec, a proton pump
inhibitor with some relief.

What is the most likely diagnosis ?

1.

A 45 yr old clerk presented to family physician for heart burn of 7 yr

duration. He has been intermittently taking prilosec, a proton pump
inhibitor with some relief. An upper endoscopy examination that was
performed recently revealed some reddish discoloration and friability
of the lower esophageal region.

What is the most likely diagnosis ?

What is the next best step in the evaluation of this patient ?

1.

A 45 yr old clerk presented to family physician for heart burn of 7 yr

duration. He has been intermittently taking prilosec, a proton pump
inhibitor with some relief. An upper endoscopy examination that was
performed recently revealed some reddish discoloration and friability
of the lower esophageal region. A biopsy of the lower esophagus was
performed and the microscopic examination revealed columnar cells
containing goblet cells.

What is most likely diagnosis ?

What is long term complication of this process ?

Gastro-esophageal reflux disease (GERD)/ Heart burn

Due to instability of lower esophageal sphincter gastric acid enters into the distal
esophagus causing intermittent burning sensation in the retrosternal region and
some times regurgitation of ingested food. Patient may also present with excessive
salivation and chronic cough.
Young children may also have GERD presents with excessive spitting and vomiting.
Predisposing factors: Tobacco, Tea, Coffee, Chocolates, Obesity, Over Eating, Hot
spicy foods, hiatus hernia.
Complications: If GERD persists for long time it causes esophagitis, ulceration,
bleeding, scar, stricture formation and Barrett's esophagus.
Treatment: Dietry modification, wt loss, PPIs, H2-blockers.
Barrett's esophagus: It is the replacement of normal esophageal epithelium( non
keratinized sq. epithelium) by stomach like epithelium which is columnar epithelium
containing goblet cells. On endoscopic examination you will see red colored friable
mucosa. Barrett's esophagus also a biggest risk factor for adenocarcinoma of lower
third of esophagus

Carcinoma of the Esophagus

World wide most common esophageal cancer is Squamous cell carcinoma. In the
Western world there is equal incidence of Sq cell carcinoma and adenocarcinoma.
Sq cell carcinoma of Esophagus: Usually occurs at upper and middle third of
esophagus. Risk factors: Alcohol and Tobacco are the most common risk factors.
Others are Achalasia, Nitrosamine containing foods, Lye, Chronic intake of Hot and
spicy foods.
Adenocarcinoma of Esophagus: Most common at lower third of esophagus. Most
common risk factor is -------------Patients are usually have few symptoms until very late in the course of disease with
symptoms being Progressive dysphagia, weight loss and fatigue. These patients have
poor prognosis, about 80% of the patient dying in the first yr because of late
presentation and its difficult to excise this much big tumor at the diagnosis.
This is the reason why periodic endoscopic surveillance with biopsy is necessary in
patients with chronic GERD.

This is X-Ray of the patient

after Barium Swallow with
Adenocaricoma of the lower
third of esophagus.

Endoscopic appearance of the

Adenocarcinoma of the
esophagus

Motility disorders of esophagus

Achalasia: Inability of LES to relax with swallowing due to reduced no. of ganglion cells
in myenteric plexus.
Etiology: Unknown in most cases
Chagas disease: Common in South America

Patient usually present with progressive dysphagia, Wt loss, regurgitation, chest

pain.

Chest X-ray: wide mediastinum with air/fluid levels.

Barium swallow will show Bird-beak sign or Rat Tail sign .

Endoscopy is important to rule out carcinoma.

Treatment is LES balloon dilatation or myotomy.

There is 5% risk for developing Sq cell carcinoma.

Esophagitis: Inflammation of the esophagus causing chest pain, Dysphagia and
Odynophagia. Etiology GERD, Infections ( Candida, CMV, HSV), radiation, uremia.
Hiatal Hernia: Gastroesophageal defect in which part of stomach protrudes above
diaphragm. Associated with GERD.
Tracheoesphageal Fistula: Congenital disorders manifesting in affected newborns as
hyper salivation and difficulty feeding with choking. Most common type( 90 %)
involves distal esophageal atresia with a connection to the trachea.

Peptic Ulcer Disease

Peptic ulcers are usually solitary, arising from exposure of the mucosal epithelium
to acid-peptic secretions. Peptic ulcer disease (PUD) occurs most often in middle
aged to older adults. The most common anatomic sites are the duodenum and the
stomach, in ratio of 4:1. H. Pylori infection is present in virtually all patients with
duodenal ulcers and 70% with gastric ulcer. Other important factors contributing to
the etiology are chronic NSAID and aspirin use, smoking, steroids.
Diagnosis: Endoscopy with or without Biopsy
Treatment: 1) Acid suppression with H2 blockers/ PPIS etc
2) Triple therapy for eradication of H. Pylori. This includes combination
of two antibiotics from Metronidazole, Amoxycillin, Clarithromycin with a PPI.
Gastric Peptic Ulcer: Located mainly at lesser curvature of the Antrum. These are
small (<3cm), solitary, round to oval shapes ulcers with sharply demarcated,
overhanging margins giving a punched out appearance.
Classic presentation: Burning epigastric pain which worsens with eating.
Associated with wait loss

Duodenal Peptic Ulcer: More commonly located at the anterior wall of first part of
duodenum. Besides H Pylori other factor contributing to the etiology are : Increased
gastric acid secretion, increased rate of gastric emptying, Blood group O, MEN type
1( parathyroid, pancreatic cancer, pituitary adenoma), Zollinger-Ellison syndrome.
Classic presentation: Burning pain 1-3 hrs after eating which is relieved by food.
Complication of PUD: Hemorrhage, Anemia( Iron deficiency anemia), Perforation,
Pyloric obstruction.
Malignant transformation is rare when it is there it is usually associated with gastric
ulcer with underlying chronic gastritis.
Zollinger-Ellison Syndrome: It is tumor of gastrin secreting cell of the pancreas
( Pancreatic gastrinoma) resulting in secretion of excessive gastrin which promotes
parietal cell hyperplasia and increased gastric acid secretion. Patient usually presents
with intractable peptic ulcer disease and diarrhea. 25 % of the Gastrinomas are part
of MEN-1.
Pyloric stenosis: Congenital hypertrophic pyloric stenosis usually presents at 2-3 wks
of age with palpable mass in he abdomen and obstruction with associated
regurgitation and persistent projectile vomiting. Waves of peristalsis are visible on
abdomen. Treatment is surgical splitting of the muscle.

Whipple Disease: Rare Infectious disease Involving almost all body organs
including small intestine, joints, lung, heart, liver, spleen and CNS. More common
in white males of ages 30-50 yrs with male to female ratio 8-9:1. Presenting with
Malabsorption, wt loss and diarrhea, GI bleeding and arthralgias. Etiology is a PASpositive, rod shaped bacilli. On microscopy: Small Bowel Lamina Propria filled with
macrophages stuffed with bacilli. Treatment: Antibiotics

Inflammatory Bowel Disease

Crohn Disease/ Regional
Enteritis

Ulcerative colitis/ Backward ileitis

Distribution

Mouth to anus

RectumColon

Most Common
site

Terminal Ileum

Rectum

Lesions

Skip/ discontinuous

Continuous

Gross

Focal ulcers with normal

intervening mucosa
Linear fissures
Cobbblestone
Thickened Bowel Wall

Extensive ulceration
pseudopolyps

Micro

Non caseating granulomas

Crypt Abscesses

Inflammation

Transmural

Mucosa and submucosa

Complications

Strictures, String sign on Barium

studies, Abscesses, Anal
Fistulas, Sinus Tracts,

Toxic Megacolon

Cancer Risk

Slight 1-3%

20% After 25 yr of disease activity