NORMAL ESOPHAGUS

NORMAL ENDOSCOPIC VIEW OF

ESOPHAGUS
NORMAL HISTOLOGY OF
ESOPHAGUS
 ENDOSCOPIC VIEW OF
ESOPHAGEO GASTRIC JUNCTION
 SYMPTOMATOLOGY OF
ESOPHAGEAL DISEASES
• Heart burn
• Dysphagia
• Pain
• Hematemesis
 CONGENITAL ANOMALIES
• Ectopic tissue rests – stomach, pancreas
• Congenital cysts – lower esophagus usually
• Bronchogenic cyst
• Pulmonary sequestration
• Agenesis
• Atresias and fistulas
 ATRESIAS AND FISTULAS
• ATRESIA – esophagus represented as a
thin non canalized cord
• Proximal blind pouch connected to pharynx
• Distal lower pouch leading to stomach
• Most commonly occurs at or near the
tracheal bifurcation
• Usually associated with a fistula – with
trachea or bronchi
 ATRESIAS AND FISTULAS
• SINGLE UMBILICAL ARTERY
• Assoc with other diseases like CHD,
neurologic disease, genito urinary diseases,
GI malformations
• ASPIRATION PNEUMONIA
ATRESIAS AND FISTULAS
 ESOPHAGEAL WEBS
• Ledge like mucosal protrusions into
esophageal lumen
• Semi circumferential
• Eccentric
• Upper esophagus common
• Can present as a cause of dysphagia
ESOPHAGEAL WEB
ESOPHAGEAL WEB
ESOPHAGEAL WEB
 CAUSES
• Congenital
• Long standing reflux esophagitis
• Chronic GVHD
• Blistering skin diseases
• IRON DEFICIENCY ANEMIA
 ESOPHAGEAL WEBS
• Iron deficiency anemia + glossitis +
cheilosis + post cricoid esophageal webs =
PLUMMER VINSON SYNDROME /
PATERSON BROWN KELLY SYNDROME /
SIDEROPENIC DYSPHAGIA
• INCREASED RISK OF POST CRICOID
ESOPHAGEAL CARCINOMA
 ESOPHAGEAL RINGS
• Concentric plate of tissue
• Distal esophagus
• TYPE A RING : above the squamo columnar
junction
• TYPE B RING / SCHATZKI RING : at the
squamo columnar junction
 ESOPHAGEAL STENOSIS
• Fibrous thickening of the esophageal wall
• Atrophy of muscularis propria
• Thin or ulcerated epithelium
• Causes :
1. Congenital
2. Inflammatory scarring
- gastro esophageal reflux
- radiation
- scleroderma
- caustic injury
. Progressive dysphagia – initially to solids
 LESIONS ASSOCIATED WITH
MOTOR DYSFUNCTION
1. ACHALASIA
2. HIATAL HERNIA
3. MALLORY WEISS TEAR
 ACHALASIA
• Failure to relax
• 3 major abnormalities
- Aperistalsis
- Partial / incomplete relaxation of LES with
swallowing
- Increased resting tone of LES
Two types : primary and secondary
 Primary achalasia
• Dysfunction of inhibitory neurons
• Degenerative changes in neural innervation
– intrinsic / extrinsic
 Secondary achalasia
• Chagas disease – trypanosoma cruzi
• Polio
• Surgical ablation of dorsal motor nuclei
• Autonomic neuropathy
• Malignancy
• Amyloidosis
• Sarcoidosis
 Morphology
• Progressive dilation of esophagus above LES
• Wall – normal / thick / thin
• Absent myenteric ganglia in body
 Clinical features
• Progressive dysphagia
• Nocturnal regurgitation
• Aspiration pneumonia
• Hazard of developing squamous cell
carcinoma
• Esophageal candidiasis
• Lower esophageal diverticulae formation
 HIATAL HERNIA
• Separation of the diaphragmatic crura
• Widening of the space between the
muscular crura and esophageal wall
• Two anatomical types
1. Axial – sliding hernia
2. Non axial – paraesophageal hiatal hernia
ESOPHAGEAL HERNIA
HIATUS HERNIA
HIATUS HERNIA - ENDOSCOPY
 Cause
• Congenital
• Acquired
 Clinical features
• Heartburn
• Regurgitation of gastric juices in the mouth
when lying down or bending forward
• Obesity
 Complications
• Ulceration
• Bleeding
• Perforation
• Strangulation
• Obstruction
• Reflux esophagitis
 DIVERTICULAE
• Outpouching of the alimentary tract that
contains ALL the visceral layers
• False diverticulum – only mucosa and sub
mucosa
• There are 3 types of esophageal diverticulae
1. ZENKER DIVERTICULUM – PHARYNGO
ESOPHAGEAL DIVERTICULUM – UES
2. TRACTION DIVERTICULUM – MID
ESOPHAGUS
3. EPIPHRENIC DIVERTICULUM – ABOVE
LES
 ZENKER DIVERTICULUM
• Disordered cricopharyngeal motor
dysfunction
• With or without GERD
• Diminished luminal size of UES
ESOPHAGEAL DIVERTICULAE
ESOPHAGEAL DIVERTICULAE
 TRACTION DIVERTICULUM
• Scarring – post TB mediastinal
lymphadenitis
• Motor dysfunction
• Congenital lesion
ESOPHAGEAL DIVERTICULAE
ESOPHAGEAL DIVERTICULAE
ESOPHAGEAL DIVERTICULAE
 Clinical features
• Accumulation of food in the diverticulum
• Dysphagia
• Food regurgitation
• Neck mass
• Aspiration pneumonia
• Nocturnal regurgitation
 MALLORY WEISS SYNDROME
• Longitudinal tear in the esophagus
• At the gastro esophageal junction
• Most common in alcoholics
• Due to severe retching / vomiting
• NO REFLEX RELAXATION OF THE LES
WITH THE ANTI PERISTALTIC WAVE OF
RETCHING / VOMITING
• Underlying hiatal hernia can be a
predisposing factor
 MORPHOLOGY
• Linear irregular lacerations
• In the axis of the esophageal lumen
• Range in length from mm to cm
• Tear may involve partial thickness of wall /
full thickness - perforation
MALLORY WEISS SYNDROME
MALLORY WEISS TEAR -
ENDOSCOPY
 CLINICAL FEATURES
• Sudden upper GI bleed
• Mild bleed / massive hemetemesis
• Heals with minimal or no residual
involvement
• Perforation = BOERHAAVE SYNDROME
 ESOPHAGEAL VARICES
• Dilated tortuous esophageal sub epithelial
and sub mucosal veins is called as
esophageal varices
• Causes : any cause of portal hypertension
1. Alcoholic cirrhosis most common cause.
2. Cirrhosis of other etiology also manifest as
varices
3. Hepatic schistosomiasis
 PORTAL HYPERTENSION

DIVERSION OF PORTAL BLOOD FLOW

CORONARY VEINS OF STOMACH

ESOPHAGEAL SUB EPITHELIAL AND SUB MUCOSAL VEINS

AZYGOS VEINS

SYSTEMIC CIRCULATION
 MORPHOLOGY
• Dilated tortuous veins
• Distal esophagus and proximal stomach
• Sub mucosal and sub epithelial channels massively
dilated
• Mucosa irregularly protruding into the lumen
• Mucosa normal / eroded and inflamed
• Rupture – massive hemorrhage into the lumen and
hemorrhage into the wall of the esophagus
• Past rupture – venous thrombosis + inflammation
ESOPHAGEAL VARICES
ESOPHAGEAL VARICES
ESOPHAGEAL VARICES
ESOPHAGEAL VARICES
ESOPHAGEAL VARICES
ESOPHAGEAL VARICES
 CLINICAL FEATURES
• Asymptomatic / massive hemetemesis
• Death due to massive bleed / hepatic coma
triggered by hemorrhage
 ESOPHAGITIS
• GERD / REFLUX
• MUCOSAL IRRITANTS – alcohol, corrosive acids, alkalis, excessive
hot fluids like tea, heavy smoking
• CYTOTOXIC ANTI CANCER THERAPY
• BACTERIA
• HSV VIRUS
• CMV VIRUS
• FUNGAL : immunosuppressed – candida, aspergillus, mucor mycosis
• UREMIA
• RADIATION
• GVHD
• AUTO IMMUNE DISEASES
• PEMPHIGOID AND BULLOUS DISORDERS OF SKIN
• CROHN DISEASE
• DRUGS
 GASTRO ESOPHAGEAL REFLUX
DISEASE (GERD) OR REFLUX
ESOPHAGITIS
• Reflux of gastric contents into lower esophagus
most important cause
• Reduced LES tone / decreased efficiency of
anti reflux mechanisms
- CNS depressants
- Hypothyroidism
- Pregnancy
- Systemic sclerosing disorders
- Tobacco exposure
- Nasogastric tube
 GERD
• Hiatal hernia – especially sliding
• Inadequate / slow clearance of refluxed
material
• Delayed gastric emptying
• Increased gastric volume
• Reduced reparative capacity of esophageal
mucosa by protracted exposure to gastric
juices
• Gastric juices +/- bile from duodenum
 MORPHOLOGY
• Inflamed esophagus – “redness”
• Inflammatory cells in the epithelial layer –
eosinophils, neutrophils, lymphocytes
• Basal zone hyperplasia
• Capillary congestion in lamina propria with
elongation of papillae
 CLINICAL FEATURES
• Dysphagia
• Heartburn
• Regurgitation of sour material
• Hemetemesis
• Melena
• Chest pain
 CONSEQUENCES
• Bleeding
• Ulceration
• Stricture formation
• Barrett esophagus formation
 BARRETT ESOPHAGUS
• It is the metaplastic change occurring in the
distal esophageal epithelium where in the
squamous epithelium is replaced by
metaplastic columnar epithelium.
• GERD IS THE SINGLE MOST IMPORTANT
CAUSE
• BARRETT ESOPHAGUS IS THE SINGLE
MOST IMPORTANT RISK FACTOR FOR
THE DEVELOPMENT OF
ADENOCARCINOMA
 CRITERIA
1. Endoscopic evidence of columnar epithelial
lining above the gastro esophageal junction
2. Histologic evidence of intestinal metaplasia
in the biopsy specimens from the columnar
epithelium
 CLASSIFICATION
1. SHORT SEGMENT < 3cm cephalad
2. LONG SEGMENT > 3cm cephalad from
the manometric gastro esophageal junction
 ENDOSCOPIC VIEW OF
ESOPHAGEO GASTRIC JUNCTION
BARRETT ESOPHAGUS
BARRETT ESOPHAGUS
BARRETT ESOPHAGUS
BARRETT ESOPHAGUS
NORMAL GASTRO ESOPHAGEAL
JUNCTION
 HISTOLOGY
• Definitive diagnosis is made when the
squamous epithelium is replaced by
columnar mucosa
• Also the columnar mucosa contains
intestinal goblet cells
• Low or high grade dysplasia can be present
BARRETT ESOPHAGUS
BARRETT ESOPHAGUS-
DYSPLASIA
 TUMORS OF ESOPHAGUS
• BENIGN:
1. EPITHELIAL
- Squamous cell papilloma
- Adenoma
2. MESENCHYMAL
- Leiomyoma
- lipoma
 Tumors
• MALIGNANT
1. EPITHELIAL:
- Squamous cell carcinoma
- Adenocarcinoma
2. MESENCHYMAL
- leiomyosarcoma
 CARCINOMA ESOPHAGUS
• Usually diagnosed late
• Aggressive spread
• Men > 50 years of age
• Varied incidence world wide
• Chinese and japanese common
• Bad prognosis
 RISK FACTORS FOR CA
ESOPHAGUS
1. ESOPHAGEAL DISORDERS:
- Long standing eophagitis
- Barrett esophagus
- Achalasia
- Hiatus hernia
- Diverticula
- Plummer Vinson syndrome
2. DIET AND LIFE STYLE
- Smoking
- Alcoholism
- Deficiency of vitamins A,C, riboflavin,
thiamine, pyridoxine
- Trace element deficiency – zinc,
molybdenum
- Fungal contamination of food stuff
- High content of nitrites / nitrosamines
3. GENETIC FACTORS:
- Tylosis : hyperkeratosis of palms and soles
- Inherited defects of cancer
 MORPHOLOGY
• Squamous cell carcinoma and
adenocarcinoma are the 2 common types
• SCC comprises almost 90% of cases
• Elderly men
• Most common in mid esophagus – 50%
lower esophagus – 30%
upper esophagus – 20%
 PRECURSOR
• DYSPLASIA  CARCINOMA IN SITU 
INVASIVE CANCER
• BARRETT ESOPHAGUS  LOW GRADE
DYSPLASIA  HIGH GRADE DYSPLASIA
 INVASIVE ADENOCARCINOMA
 SCC
1. Polypoid fungating type
2. Ulcerating type
3. Diffuse infiltrative type
MICRO : well differentiated to poorly
differentiated squamous cell carcinoma
 ADENO CARCINOMA
• Usually arises in a setting of Barrett
esophagus
• Lower and mid esophagus common sites
• Nodular, elevated masses in lower
esophagus
MICRO :
Most of them are well differentiated mucin
producing tumors
 CLINICAL FEATURES
• Weight loss
• Anorexia
• Fatigue
• Weakness
• Pain during swallowing
• Dysphagia
• Spreads very soon because of the extensive
lymphatic network
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
CARCINOMA ESOPHAGUS
SQUAMOUS CELL CARCINOMA
ESOPHAGUS
CARCINOMA ESOPHAGUS -
STAGING