PATHOLOGY RAJEEV KUMAR, MD
GI SYSTEM • 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 ?
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 ?
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, PPI’s, 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
Achalasia: Inability of LES to relax with swallowing due to reduced no. of ganglion cells in myenteric plexus. Etiology: Unknown in most cases Chaga’s 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/ PPI’S 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 PAS-positive, rod shaped bacilli. On microscopy: Small Bowel Lamina Propria filled with macrophages stuffed with bacilli. Treatment: Antibiotics