PATHOLOGY OF THE

GASTROINTESTINAL TRACT
Ismail Matalka , FRCPath
Department of Pathology
Jordan University of Science & Technology
Irbid Jordan
Modified and presented by:
Huda M. Hammad, BDS, MS, FRCD(C),
Diplomate, ABOMP
Faculty of Dentistry

THE ALIMENTARY (DIGESTIVE) SYSTEM

Oral cavity (including salivary glands)

Esophagus
Stomach
Small intestine
Colon
Appendix
Liver
Biliary tract
Pancreas

Image of undetermined source

PATHOLOGY OF THE
GASTROINTESTINAL TRACT
The Oral Cavity

ANATOMY & HISTOLOGY OF

THE ORAL CAVITY

Anatomy
Orifice to digestive & respiratory tracts.
Lips, buccal mucosa, tongue, soft & hard palate.
Teeth & periodontal tissues.

http://www.apsubiology.org/anatomy/2020/2020_Exam_
Reviews/Exam_3/CH23_Oral_Cavity_I_Walls.htm

ANATOMY & HISTOLOGY OF

THE ORAL CAVITY

www.vistadental.com

ANATOMY & HISTOLOGY OF

THE ORAL CAVITY

Histology
Lined by nonkeratinized squamous
epithelium (hard palate,
gingivae & dorsal
tongue are keratinized).
Minor salivary glands &
sebaceous glands in
lips & buccal mucosa.
Lymphoid tissue.
http://www.lab.anhb.uwa.edu.au/
mb140/corepages/oral/oral.htm

DISEASES OF THE

ORAL CAVITY

Can be broadly divided into:

Diseases affecting oral soft tissues.
Diseases affecting the teeth and periodontal
tissues.
Diseases affecting the jaw bones.
Diseases affecting the salivary glands.
Extra-oral diseases can sometimes involve the mouth,
e.g. skin diseases, leukemia, Crohns disease.
Only some conditions, including congenital and
developmental anomalies, and diseases affecting the
oral mucosa and salivary glands are included in this
lecture.

DISEASES OF THE

ORAL CAVITY

Congenital and developmental anomalies, e.g.

cleft lip & cleft palate, macroglossia, branchial
cleft cysts
Inflammatory & infectious lesions: aphthous
ulcers, herpetic stomatitis, candidiasis.
Pre-malignant lesions: leukoplakia,
erythroplakia.
Tumors: squamous cell carcinoma.
Salivary gland inflammatory conditions.
Salivary gland tumors.

http://cleftlipcleftpalate5.blogspot.com/2011/0
9/what-causes-cleft-lip-and-palate.html

Cleft Lip & Cleft Palate

Cleft Lip & Cleft Palate

From: Contemporary Oral &

Maxillofacial Pathology, Sapp
et al. 2nd edition

Macroglossia

Macroglossia caused by lymphangioma

http://ispub.com/IJORL/3/2/13713

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

APHTHOUS ULCERS (CANKER SORES)

Extremely common, up to 40% of population.

Single or multiple shallow fibrin-coated painful
ulcers of oral mucosa, usually <1 cm, may
coalesce.
Unknown etiology (?viruses, hypersensitivity).
Triggered by stress, fever, menstruation,
pregnancy, certain foods; may be familial.
May be associated with inflammatory bowel
disease & Behet syndrome.
Self-limiting in a few days to weeks depending on
type.

www.quizlet.com

Major aphthous ulcers

www.studyblue.com

Minor aphthous ulcers

Herpetiform aphthous ulcers

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

HERPETIC STOMATITIS

HSV I>>II; person to person transmission.

After primary infection which is usually asymptomatic,
virus will persist in ganglia in dormant state.
Reactivation: fever, sun or cold exposure, URTI, ..

http://pocketdentistry.com/7-viral-infections/

http://163.178.103.176/Fisiologia/neur
ofisiologia/Objetivo_1/Herpes.htm

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

HERPETIC STOMATITIS

Herpes labialis: cold sores or fever blisters.

http://pocketdentistry.com/7-viral-infections/

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

HERPETIC STOMATITIS
Infected cells undergo ballooning degeneration:
swollen, eosinophilic cytoplasm, pale vesicular nuclei.
Vesicular lesion, edema, degeneration of epidermis
Tzanck test: intranuclear inclusions & giant cells
http://mydermpath.com/index.php?option=
com_dermpath&view=diagnosisdetail&id=
292&pid=691

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

HERPETIC STOMATITIS

In immunocompromised: virulent disseminated

infection: gingivostomatitis, encephalitis ...

Image of undetermined source

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

FUNGAL INFECTIONS

https://dentistryandmedicine.bl
ogspot.com/2011/11/whitelesions-of-oral-mucosa.html

Candida albicans is part of normal flora (30-40%)

Oral candidiasis (moniliasis, thrush): common in:
Diabetes mellitus
Anemia
Antibiotic or glucocorticoid Rx
Immunodeficiencies & debilitating diseases
Soft white cheese-like plaques
http://www.thrushbabies.com/ba
by-thrush-in-the-mouth/

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

FUNGAL INFECTIONS

Minimal- marked ulceration with inflammatory

exudate and fungal microorganisms
(pseudohyphae)
In vulnerable patients, disease may spread

http://www.microbiology
book.org/mycology/myc
ology-3.htm

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

ACQUIRED IMMUNODEFICIENCY
SYNDROME (AIDS)

HIV infection is associated with different lesions

in the oral cavity
Candidiasis
Herpetic vesicles
Other opportunistic infections

Image of undetermined source

http://www.hiv.va.gov/provider/imagelibrary/oral.asp?post=1&slide=133

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

ACQUIRED IMMUNODEFICIENCY
SYNDROME (AIDS)

HIV infection is associated with different lesions

in the oral cavity
Kaposis sarcoma: multifocal vascular tumor, present
in 25% of AIDS patients; HSV8

http://www.hiv.va.gov/provider/image
-library/oral.asp?post=1&slide=175

ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY

ACQUIRED IMMUNODEFICIENCY
SYNDROME (AIDS)

HIV infection is associated with different lesions

in the oral cavity
Hairy leukoplakia: white patches with hairy surface:
caused by EBV
rare, but seen mainly in AIDS
histology shows acanthosis, hyperkeratosis

http://medical-photographs.com/48white-lesions-of-the-oralmucosa.html#hairy-leukoplakia

PRE-MALIGNANT LESIONS OF
THE ORAL CAVITY

PRE-MALIGNANT LESIONS OF THE ORAL CAVITY

LEUKOPLAKIA

A clinical term used to describe a whitish welldefined mucosal patch or plaque caused by
epidermal thickening or hyperkeratosis.
Older men; associated with tobacco, chronic
friction (dentures), alcohol & irritant foods; HPV
link.

http://diseasesforum.com/leukoplakia/

PRE-MALIGNANT LESIONS OF THE ORAL CAVITY

LEUKOPLAKIA

Microscopically, they vary from hyperkeratosis without

dysplasia to mild to severe dysplasia or CIS.
Only histological examination distinguishes these
changes.
3-6% transform into squamous cell carcinoma.
http://cancermed.blogspot.com/2011/10/
overview-of-classification-and.html

PRE-MALIGNANT LESIONS OF THE ORAL

CAVITY

LEUKOPLAKIA
Epithelial dysplasia. A, Mild
epithelial dysplasia with
cytologic atypia confined to
the lower epithelial strata. B,
Moderate epithelial dysplasia
contains several layers of
atypical cells; however, the
upper half of the epithelial
thickness remains with a
normal-appearing
maturational sequence. C,
Severe epithelial dysplasia
with essentially fullthickness epithelial cell
atypia, without evidence of
invasion.

http://clinicalgate.com/oral-mucosal-lesions/

PRE-MALIGNANT LESIONS OF THE ORAL CAVITY

ERYTHROPLAKIA

Red velvety areas which may remain level with

or slightly depressed in relation to surrounding
mucosa.
Greater tendency for epithelial cell atypia and
marked dysplasia than leukoplakia.

http://www.exodontia.info/Erythroplakia
_Erythroplasia.html

PRE-MALIGNANT LESIONS OF THE ORAL CAVITY

ERYTHROPLAKIA

Hyperkeratosis is less frequent; red color is due to

intense inflammation and vascular congestion.
Higher risk (50%) of malignant transformation (the risk
corresponds to the degree of atypia).
Erythroleukoplakia: speckled leukoplakia; mixture of
erythroplakia and leukoplakia.

http://www.exodontia.info
/Leukoplakia.html

MALIGNANT TUMORS OF THE ORAL CAVITY

SQUAMOUS CELL CARCINOMA

MALIGNANT TUMORS OF THE ORAL CAVITY

SQUAMOUS CELL CARCINOMA

Represent 90% of oral

cavity malignancies
(3% of all malignant
tumors); M > F.
Lip > ant. floor of
mouth > tongue >
palate.

MALIGNANT TUMORS OF THE ORAL CAVITY

SQUAMOUS CELL CARCINOMA

Etiology: smoking, smokeless tobacco, protracted

irritation (e.g. dentures), chronic dental & oral infections,
sunlight, heat, alcohol, epithelial atrophy, HPV.

Images of undetermined sources

MALIGNANT TUMORS OF THE ORAL CAVITY

SQUAMOUS CELL CARCINOMA

White/ red plaque, mucosal thickening or ulcer

http://www.killthecan.org/factsfigures/cancer-pictures/

MALIGNANT TUMORS OF THE ORAL CAVITY

SQUAMOUS CELL CARCINOMA

Invasive &/or in situ carcinoma; well differentiated to

undifferentiated,

http://www.chsjournal.org/archive/vol39-no22013/original-papers/lip-squamous-carcinomaepidemiologic-clinical-evolutive-and-therapeuticalaspects

http://www.jomfp.in/viewimage.asp?img=JOralMaxill
ofacPathol_2013_17_1_45_110720_f10.jpg

MALIGNANT TUMORS OF THE ORAL CAVITY

SQUAMOUS CELL CARCINOMA

Spread to local LN (submandibular, high jugular)

Px: depends on location (e.g. lip), grade, stage

50% lead to death in 5 years; overall 5 YS without L.N mets
is 40% after chemo & radio; and 20% with L.N mets

Images of undetermined source

DISEASES OF THE

SALIVARY GLANDS

Image of undetermined source

DISEASES OF THE

SALIVARY GLANDS

Inflammation

Viral sialadenitis
Bacterial sialadenitis
Autoimmune sialadenitis
Sialolithiasis

Tumors
Benign
Pleomorhpic adnoma (mixed tumor)
Warthins tumor

Malignant
Carcinoma ex-pleomorphic adenoma
Mucoepidermoid carcinoma
Adenoid cystic carcinoma

Mickuliczs syndrome

INFLAMMATIONS OF THE SALIVARY GLANDS

VIRAL SIALADENITIS

Most common cause is mumps, which usually

affects the parotid gland (epidemic parotitis)
70% bilateral parotid; 20% unilateral; 10% others
Mumps is an acute contagious childhood disease
Paramyxovirus, acquired by respiratory droplets

INFLAMMATIONS OF THE SALIVARY GLANDS

VIRAL SIALADENITIS

Usually self limited, but may lead to

complications, which are commoner in adults:
Pancreatitis
Orchitis: usually unilateral; rarely leads to
infertility
CNS inflammation: rare but serious

http://www.rocketswag.com

INFLAMMATIONS OF THE SALIVARY GLANDS

AUTOIMMUNE SIALADENITIS

Sjgrens syndrome: inflammation of salivary

glands & mucus-secreting glands of nasal
mucosa (resulting in dry mouth or xerostomia)
and lacrimal glands (resulting in dry eyes or
keratoconjunctivitis sicca).

http://bookcoverimgs.com/sjogren-39-s-skin-rash/

INFLAMMATIONS OF THE SALIVARY GLANDS

AUTOIMMUNE SIALADENITIS

90% are females; parotid

enlargement in 50%.
May be primary or secondary
(60%) to other autoimmune
disease e.g. RA, SLE,
polymyositis.
Lymphocytic infiltration & fibrosis
RF, ANAs +/-; antiribonucleoprotein SS-A & SS-B
Abs.
High risk to develop lymphomas.
http://www.nejm.org/doi/full/1
0.1056/NEJMicm1210527

INFLAMMATIONS OF THE SALIVARY GLANDS

SIALOLITHIASIS & NONSPECIFIC

SIALADENITIS

Bacterial
Secondary to ductal obstruction by stones
(sialolithiasis) in major excretory duct
Usually unilateral

http://am-medicine.com/2013/12/neck-swellings-typesdefinitions-etiology-clinical-features-investigationsdifferential-diagnosis-and-treatment-2.html

INFLAMMATIONS OF THE SALIVARY GLANDS

SIALOLITHIASIS & NON-SPECIFIC

SIALADENITIS

http://www.ghorayeb.com/Parotitis
Acute.html

Pathogenesis: impacted food debris & edema around

orifice following injury
Ductal dilatation, periductal inflammation, secondary
bacterial invasion & suppuration
Predisposing factors: Hx of major surgery, dehydration,
long-term phenothiazines Rx
http://bestpractice.bmj.com/bestpractice/monograph/1038/resourc
es/images.html

SALIVERAY GLANDS

TUMORS

Relatively uncommon; 2% of tumors in humans

80% of tumors occur in parotid gland
Equal M:F ratio; all ages [6th - 7th decade]
Most of these neoplasms are benign: 70-80% of
parotid tumors and only 50% of submaxillary
tumors
c/o: mass at angle of jaw
Wide histologic variations
Benign: pleomorphic adenoma, Warthins
tumor
Malignant: carcinoma ex-pleomorphic
adenoma, mucoepidermoid carcinoma, adenoid
cystic carcinoma

TUMORS OF THE SALIVARY GLANDS

PLEOMORPHIC ADENOMA

AKA: mixed tumor:

Most common tumor
(65-80%) of the
salivary glands
Slowly growing welldemarcated, mostly
arising from
superficial parotid

TUMORS OF THE SALIVARY GLANDS

PLEOMORPHIC ADENOMA

Pathology: heterogeneous histology with epithelial

elements, myxoid stroma, often containing chondroid foci
or, rarely, bone
Px: recurrence after surgery: 10%
Malignant transformation: 15% in parotid, 40% in
submandibular gland

http://peir.path.uab.edu/library/
picture.php?/12601

TUMORS OF THE SALIVARY GLANDS

WARTHINS TUMOR

AKA: Papillary cystadenoma lymphomatosum

Benign slowly growing tumors
5-10% of all parotid tumors; extremely rare in
other salivary glands
http://atlasgeneticsoncology.org/T
umors/WarthinsTumID5424.html

TUMORS OF THE SALIVARY GLANDS

WARTHINS TUMOR

Pathology: composed of cystic spaces lined by tall

columnar cells overlying abundant lymphoid tissue
Histogenesis: vestigial embryonic remnants of
branchial cleft origin?
Rx: cured by surgical excision

PATHOLOGY OF THE SALIVARY GLANDS

MICKULICZS SYNDROME

Combination of salivary and lacrimal glands

enlargement with xerostomia
May be due to many causes:
Sarcoidosis
Leukemia/lymphoma
Sjgrens syndrome
It describes a clinical presentation; it is not a
pathological diagnosis.
Therefore, many recent textbooks have
abandoned this term since it is confusing.

END OF PART I