C H A PTER
20
Esophagus
Christopher A. Moskaluk
NORMAL ANATOMY AND HISTOLOGY
Variants of Normal
NEOPLASTIC AND MASS LESIONS
Classification
General Considerations
Benign Masses and Neoplasms
Malignant Neoplasms
NON-NEOPLASTIC CONDITIONS
Congenital Malformations and Acquired Structural Anomalies
NORMAL ANATOMY
AND HISTOLOGY
The normal esophagus is a hollow tubelike organ with an
average length of 23 cm to 25 cm in adults. For the pur-
poses of classifying and staging esophageal malignancies,
the esophagus is divided into four segments (Table 20-1).1
The normal mucosa is nonkeratinizing stratified squamous
epithelium along its whole length. At the gastroesophageal
(GE) junction, there is an abrupt transition to gastric epi-
thelium. In some individuals, this transition is serrated,
with interdigitating mucosal projections of 3 mm to 5 mm
(hence its designation as the “Z-line”); in others, the transi-
tion is straight.2 The lamina propria underneath the esoph-
ageal epithelium contains scattered cardiac-type glands, so
called because they resemble the mucus-secreting glands of
the gastric cardia. These glands are most common in the
distal esophagus. They secrete neutral mucins that stain
with periodic acid–Schiff (PAS) but not with alcian blue
at acidic pH. The submucosa contains a second group of
glands that are considered to be a continuation of the minor
salivary glands (Fig. 20-1). They secrete an acidic mucin
that stains with alcian blue at pH 2.5. The glands are con-
nected to the surface of the mucosa by ducts that are
initially lined by a single row of cuboidal epithelium; this
changes into stratified squamous epithelium closer to the
surface.2 The muscularis propria is a mixture of striated and
smooth muscle in the upper half of the esophagus, with
smooth muscle predominating. The lower half of the esoph-
agus has muscularis propria composed entirely of smooth
muscle.3 The muscular wall is divided into two coats: an
inner circular layer and an outer longitudinal wall. The
majority of the esophagus is surrounded by an adventitia in
Infectious Lesions
Idiopathic Inflammatory Conditions
Bullous and Desquamative Diseases
Injury Due to Exogenous Agents
Esophageal Involvement in Systemic Diseases
Miscellaneous Conditions
which fascia encircles the esophagus to form a sheathlike
structure, but it is not surrounded by a mesothelial layer.
As in other parts of the gastrointestinal (GI) tract, the
esophagus is supplied by the autonomic nervous system,
with ganglia present in the submucosa (Meissner’s plexus)
and in between the layers of the muscularis propria
(Auerbach’s plexus).
Variants of Normal
Glycogenic Acanthosis
Glycogenic acanthosis is present in 25% of the population
and should be considered a variant of normal. It presents
as white nodules or small plaques, primarily in the distal
third of the esophagus; the nodules usually measure no
more than 1 cm but may rarely coalesce into larger plaques.
This condition may be confused macroscopically with can-
didal plaques or leukoplakia. Histologically, there is focal
hyperplasia of the prickle cell layer, which contains abun-
dant glycogen.2
Gastric Heterotopia
Heterotopic gastric mucosa, appearing as small patches,
may be found in the esophagus in up to 4% of the popula-
tion. It is most common within the first 3 cm of the esoph-
agus (hence its clinical designation as “inlet patch”). The
mucosa can be gastric cardiac type (mucous glands), fundic
type (parietal and chief cells), or a mixture of both.2 The
same pathologic processes that occur in the stomach can
affect ectopic gastric mucosa, including Helicobacter pylori
infection, intestinal metaplasia, pancreatic metaplasia, and
neoplastic transformation.4-7
n  637