Gastrointestinal system Part II The oesophagus

A muscular tube Conduction of food and drink Sphincters at top and bottom

Histology Non-keratinising squamous epithelium Submucosa Lamina properia Muscularis mucosa Muscular layer Advanticia No mesothelia coverage

Congenital and mechanical disorders (1) Atresia – often with fistula to trachea Hiatus hernia (presence of stomach in thoracic cavity) – due to increased intra-abdominal pressure Sliding hernia>95% Paraesophageal<5%

Hiatal hernia…….. Heart burn&Regurgitation Reflux esophagitis Esophageal ulcer Strangulation

…Mechanical disorders (2) Achalasia  Failure of relaxation of lower oesophageal sphincter (destruction or degeneration of nerve plexus)  Similar features in Chagas’ disease (South American trypanosomiasis)

Achalasia….. Apristalsism Lack or decreased LES relaxation Esophageal rest hypertonisity Pre stenotic dilatation&muscle hypertrophy Dysphagia,regorgitation,aspiration SCC 5% in younger patient

Oesophageal varices Localised dilatation of lower oesophageal veins Secondary to portal hypertension (portal vein thrombosis or hepatic cirrhosis) Haemorrhage can be catastrophic

Mallory weiss syndrome Longitudinal tearing in GE junction Hyperemesis Hematemesis Superficial or deep Mediastinitis No sequela

Inflammation (oesophagitis) Acute infective – Herpes virus, Candida. Both seen most commonly in immunosuppressed. Ingestion of corrosives Chronic reflux through lower oesophageal sphincter(most common) Uremia,chemotherapy,radiation Sliding hiatal hernia

Herpes oesophagitis Punched-out ulcers Viral intranuclear inclusions Formation of multinucleated giant cells (cytopathic effect)

Herpes oesophagitis

Candida oesophagitis Haemorrhagic mucosa with white plaques Fungal hyphae and yeast forms on microscopy

Reflux oesophagitis Common – often without symptoms Mucosa exposed to acid-pepsin and bile Increased cell loss and regenerative activity

Consequences of reflux oesophagitis Ulceration Stricture Glandular metaplasia (Barrett’s oesophagus) Carcinoma

Barrett’s oesophagus Columnar epithelial cells in lower oesophagus Variable extent Presence of goblet cells “intestinal metaplasia” associated with risk of progression to dysplasia/cancer X

Oesophageal neoplasms Benign tumours (rare): squamous papilloma, leiomyoma Malignant tumours  Squamous carcinoma  Adenocarcinoma Presenting symptom - dysphagia

Epidemiology of oesophageal cancer Squamous carcinoma commonest worldwide 1-2% all cancer death Adenocarcinoma has very different risk factors and is now the commonest type in Europe/N.America Scc >90% in other parts In US 50%

Squamous carcinoma High incidence in Southern Africa (incl. Malawi), China, Iran Probably diet related (A and B vitamin deficiency, fungal contamination) – tobacco and alcohol also risk factors Associated with chronic non-specific oesophagitis

Gross morphology Fungative masses penetrating ulceration Infiltration into the eso.wall

Squamous carcinoma Often large exophytic occluding tumours Invasive disease preceded by dysplasia and carcinoma in situ

Adenocarcinoma Occurs in lower oesophagus Often associated with Barrett’s oesophagus (progresses through dysplasia to cancer)

Clinical course of oesophageal cancer Grim! (even with best available resource) Tumours have commonly spread to regional nodes and/or liver at presentation No peritoneal lining in mediastinum – local invasion (heart, trachea, aorta) often limits surgery

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