Pathology of

gastrointestinal
tract I
- Esophagus
- Stomach

MUDr. Helena Skálová

Esophagus
• 25 cm

Wikibooks
Inborn defects
• Atresia
• Tracheoesophageal fistula

Robbins and Contran Pathologic Basis of Disease, 7th edition

Motoric dysfunction of esophagus
• Achalasia:
- loss of cells in plexus myentericus
- loss of peristalsis
- inability od lower eosphageal
sphincter to relax
- megaesophagus
• Hiatal hernia:
- widening of hiatus diaphragmaticus
- displacement of GE junction and
part of stomach to dorsal
mediastinum
- sliding, paraesophageal, mixed
Robbins and Contran Pathologic Basis of Disease, 7th edition
Motoric dysfunction of esophagus
• Diverticules:
- Zenker – FE junction
- tractional – postinflammatory
fixation to LN
- epiphrenic – defective coordination
of peristalsis and relaxation of
sphincter
• Mallory-Weiss syndrome:
- laceration of distal esophagus
and GE junction
- risk of bleeding, rarely
perforation
- after strong vomiting
Robbins and Contran Pathologic Basis of Disease, 7th edition
Esophageal varices
• Portal hypertenzion (90% pacients with cirrhosis, e.g. alcoholic)

• Portocaval anastomoses → varices in submucosa of terminal

esophagus

• Asymptomatic → rupture
→ massive hematemesis

• 40-50% mortality in each episode

• 50% rebleeding

• Therapy: varix sclerotization,

baloon tamponade
Esophagitis
• 5% adult population

Etiology:
- Gastroesophageal
reflux disease
- Consumption of strong
iritants
(acids, lyes, alcohol +
smoking, hot liquids)
- Infection –
immunosupressed
pacients
(HS, CMV, candida,
aspergilus)
Reflux esophagitis
(= gastroesophageal reflux disease)
• Reflux of acidic gastric content into distal
esophagus over insufficient lower sphincter
- decreased tonus of the sphincter (pregnancy, calming drugs
alcohol + smoking)
- sliding hiatal hernia

• Adults > 40 y.o., children

• Symptoms:
heart burn (chest pain), dysphagia,
regurgitation of acidic gastric content
→ cough

• Micro: chronic inflammation in distal esophagus,

Barrett esophagus
Barrett esophagus
• 10% pacients with longterm
symptomatic GE reflux

• 40-60 years old, white men

• Response to longterm
irritation → intestinal
metaplazia

• Precancerosis:
Dysplazia → adenocarcinoma
(30-40x higher risk)
Tumors of esophagus
Benign Malignant
• Squamocellular
• Leiomyoma carcinoma

• Adenocarcinoma
• Fibroma, lipoma,
hemangioma …
Prognosis: bad, high mortality

• Squamocellular papiloma Gross: exophytic, flat, ulcerated

Symptoms - late:
dysfagia, obstruction,
bleeding, weight loss
Adenocarcinoma
• Carcinoma of distal esophagus
in 10% pacients with Barrett
esophagus

• Symptoms include heart burn

• Median 60 y.o., white men

• Higher incidence: developed

countries

• Micro: glandular mucous producing

intestinal-type carcinoma

• Invasion to stomach, mediastinum

• Metastases in regional LN
Sqamocellular carcinoma
• Whole esophagus, mainly
upper 2/3

• Adults, > 50 y.o., men

• Higher incidence: developing

countries

• RF: alcohol, smoking

• Invasion into surrounding

structures (trachea, aorta,
mediastinum, pericardium …)
• Metastases in regional LN
Stomach
Gastritis
= inflammation of gastric mucosa
 Symptoms:
- dyspepsia of upper type, pain in epigastrium, nausea,
vomiting, haematemesis, melaena
- chronic often asymptomatic

 Histological evaluation necessary

 2 types:
- Acute (neutrophils, haemorrhage, erosions)
- Chronic (lymocytes, plasma cells + neutrophils in acute
relaps)
Acute gastritis
 Haemorrhagic, erosive

 Risk factors - etiology:

- NSAID (Aspirin)
- Alcohol, smoking
- Acid burn (suicide attempt)
- Stress (shock, trauma, burns, surgery, sepsis)

 Complications: haemoptysis (also massive), melaena

 Common disease
 25% pacients using aspirin daily (rheumatoid arthritis)

 Gastropathy – irritation, erosions or mucosal bleeding

without inflammation, may precede gastritis
Chronic gastritis
 Atrophy, hypertrophy
 Intestinal metaplazia
 Dysplazia

 RF for gastric cancer

 Etiology:
- Helicobacter pylori - B
- Autoimmune - A
- Toxic (alcohol, smoking) - C
Helicobacter pylori
Nonsporulating Gram- rod
• 1983 Campylobacter pyloridis

• Specialization for life in stomach:

- Flagellum
- Ureasis (urea → CO₂ + NH₃)
- Expression of bacterial adhesins
- Expression of bacterial toxins → peptic ulcer

• Antral gastritis, ↑ secretion of HCl → peptic ulcer

• Pangastritis, ↓ secretion of HCl, RF for ca
• Association:
- chronic gastritis, peptic ulcer
- gastric carcinoma and lymphoma (MALT)

• Therapy: antibiotics, inhibitors of proton pump

Autoimmune gastritis
• ‹ 10% gastritides

• Autoantibodies angainst parietal cells

(e.g. receptor for gastrin, intrinsic factor)

• Destruction of glands, atrophy of mucosa → ↓ production of HCl

and intrinsic factor

• Malabsorption of vitamin B12

• Pernicious anemia:
- megaloblastic anemia
- demyelinization of dorsolateral tracts (motoric and senzoric)
- Hunter glossitis

• RF for carcinoma, carcinoid

Peptic ulcer
Gastroduodenal ulcer disease
• Etiology: H. pylori, ischemia, NSAID, alcoholic liver cirrhosis
• H. pylori: 100% duodenal, 70% gastric
(ulcer in 10-20% infected patients)
• Chronic, solitary lesion, relapsing, spontaneously healing
• Duodenum, antrum and lesser curvature (↑ HCl)
• Adults, more men
• Symptoms:
- Pain 1-3 hrs after meal and in the night, relief after meal
- Nausea, vomiting, flatulence, weight loss
• Dif. dg.: CARCINOMA!!!
• Zollinger-Ellison syndrome – gastrinoma (NET usually in pancreas,
duodenum)
 Acute ulcer
• NSAID
• Stress ulcers – shock
• Pathogenesis uncertain, role of ischemia
Complications of gastric ulcer
• Bleeding
- 15-20% pacients, 1/4 †

• Perforation, penetration
- 5% pacients, 2/3 †

• Stenosis by edema and

strictures
- 2% pacients
- pylorus, duodenum
Tumors of stomach
Polyps
Benign
• Hyperplastic polyp
• Fundic gland polyp
 Adenoma
 Leiomyoma

Malignant

• Carcinoma (93%)
• Lymphoma (4%)
• GIST (2%)
• NET = carcinoid (3%)
Stomach carcinoma
 One of the most frequent worldwide (↑↑↑Japan)

 High mortality, decrease from 60‘ (endoscopy)

 M:W = 2:1

 RF: H. pylori (5-6x) – chronic gastritis, diet

 Symptoms - late:
↓ weight, pain, anorexia, vomiting, haemorrhage, anemia

!
 2 main histological types:
- Intestinal (resambles intestinal adenocarcinoma)
- Diffuse (poorly differenciated, often with signet-ring cells)
Stomach carcinoma

 Early

 Advanced

 Local invasion: duodenum, pancreas, retroperitoneum

 Metastases: region and distant LN (Virchowov), peritoneal

spread, liver, lungs, ovaries (Krukenberg tumor)
Other malignant gastric tumors
 Lymphoma (MALToma, low grade)
- H. pylori (regression after atb elimination)
- mucosa, submucosa
- symptoms: nonspecific (nausea, dyspepsia)

 GIST
- Cajal cells
- solitary, multiple
- 30% malignant
(abdominal spread,
distatnt metastases)

 Neuroendocrine tumor = carcinoid

Stomach NET
(neuroendocrine tumor)
• Neuroendocrine tumor (NET)
• Neuroendocrine carcinoma (NEC)

Predisposition:
• Autoimmune chronic atrophic
gastritis
• MEN1 (syndrome of multiple
endocrine neoplasia)
• Zollinger-Ellison syndrome
– gastrinoma (NET usually in
pancreas, duodenum)

• Solitary, multiple
• Small tumor
• Growth in deep LPM and submucosa,
covered by mucosa

• May produce serotonin, histamin,

ATCH, gastrin …
Bleeding into gastrointestinal tract
• Hematemesis:
- vomiting of blood
- from upper GIT (oral cavity, esophagus, stomach)

• Melaena:
- digested (black) blood in stools
- from upper GIT (oral cavity, esophagus, stomach)

• Enterorrhagia:
- fresh (red) blood in stools
- from lower GIT (intestines, anus)

• Other symptom: anaemia

 Differential diagnosis:
Hematemesis and melaena
Oesophagus
-Varices
-Reflux oesofagitis
-Oesophageal carcinoma
-Sy Mallory-Weiss
-Rupture of aortal aneurysm
-Acid burns
-Foreign body
Stomach
-Varices of gastric carcia
-Gastritis (aspirin, alcohol)
-Ulceration (incl. Zollinger-Ellison sy)
-Stomach carcinoma
-Vascular malformation
-Complication of endoscopy

Duodenum
-Ulceration
Other:
-Hemorrhagic diathesis
-Tumor
-Trauma
-M. Crohn
-Hemoptysis
-Penetration of bile stone into duodenum
-Bleeding from oral cavity
-Acute hemorrhagic-necrotizing pancreatitis
Differential diagnosis:
Enterorrhagia

• Hemorrhoidal varices
• Diverticulosis
• Ulcerative colitis, Crohn disease
• Bacterial enterocolitis
• Carcinoma, larger adenoma
• Iatrogenous (after polypectomy, postradiation, NSAID …)
 Summary
• Esophagitis:
- reflux → chronic inflammation → intestinal metaplasia → adenocarcinoma
• Esophageal tumors:
- adenocarcinoma, squamous carcinoma
- bad prognosis

• Helicobacter pylori:
- chronic gastritis, peptic ulcer, stomach adenocarcinoma, lymphoma
• Stomach tumors:
- adenocarcinoma (intestinal, diffuse)

• Bleeding into GIT:

- hematemesis, melaena, enterorrhagia, anaemia
- upper, lower GIT, adjacent structures