Professional Documents
Culture Documents
GIT, Alem
GIT, Alem
GIT, Alem
Alemwosen T.
ORALCAVITY
Inflammations
Herpes simplex virus infection
- most are caused by HSV-I
Lymphoma
Diffuse Large B-cell Lymphoma (Old age & AIDS)
MALToma
Plasmacytoma
Melanoma
Leukemic infiltrates
22
Contd
Odontogenic cysts and tumors
Ameloblastoma
True neoplasm & arises from odontogenic
epithelium
It is commonly cystic, slow growing, and locally
destructive
Odontoma commonest lesion
Hamartomatous- extensive deposition of enamel and
dentin
Radicular cyst Cyst related to the tooth root,
usually after inflammation
Keratocyst- Cyst of dental lamina origin, lined by
stratified squames
23
Radiographic feature
Multilocular radiolucent lesion, soap bubble / honey combed
Buccal & lingual cortical expansion
resorption of the roots of teeth
27
Keratocyst
28
Diseases of Salivary Glands
Inflammation (Sialadenitis)
Traumatic, viral, bacterial, autoimmune origin
Mucoceles most common cystic lesion of oral cavity,
follows duct obstruction after inflammation
Mumps- most common viral sialadenitis
Sjogren syndrome- an autoimmune disease
Sialolithiasis and Chr. Nonspecific inflam
Sialolithiasis and non specific
Sialadenitis
Most often bacterial & involves submandibular
glands
Pathogenesis:
dehydration with decreased secretory function & may
predispose to infection
Usually, secondary to ductal obstruction by stones
Unilateral involvement of single gland is the rule
SSx: painful enlargement and sometimes purulent
ductal discharge
Chronic sialadenitis
31
Neoplasms of salivarygland
Classification
Benign Malignant
Pleomorphic adenoma Mucoepidermoid carcinoma
Warthins tumor Adenocarcinoma
Oncocytoma Acinic cell carcinoma
Basa cell adenoma Adenoid cystic carcinoma
Ductal papillomas Squamous cell carcinoma
35
Warthin tumor
Papillary cystadenoma lymphomatosum
Second most common, commonly in old age
Almost always arises in the parotid gland
Spaces lined by a double layer of epithelial cells resting
on a dense lymphoid stroma sometimes bearing
germinal centers
Bilateral or multicenteric
Warthins T.
37
Mucoepidermoid carcinoma
Composed of mixtures of three cells:
squamous cells, mucus secreting cells, and intermediate cells
Occur mainly in the parotids
15% of all salivary gland tumors
Most common form of primary malignant tumor of
salivary glands
Cords, sheets, or cystic configurations of squamous,
mucous, or intermediate cells
Low grade lesions tend to be composed of largely mucus
secreting cells (cystic)
High grade tumors are composed largely of squamous
cells with only a scattering mucus secreting cells (solid)
Mucoepidermoid carcinoma
39
Mucoepidermoid carcinoma
40
Adenoid cystic carcinoma
most common neoplasm in the minor salivary glands
Composed of small cells, having dark, compact nuclei and
scanty cytoplasm
The cells tend to be dispersed in tubular, solid, or
cribriform patterns
The spaces between tumor cells are filled with a hyaline
material
Most painful (perineural invasion) salivary gland
neoplasm
Adenoid cytic carcinoma
42
Acinic cell tumor
Composed of cells resembling the normal serous cells
of salivary glands
Most arise in the parotid
Bilateral or multicenteric
The cells have apparent cleared cytoplasm
The cells are disposed in sheets or microcystic,
glandular, follicular, or papillary patterns
Little anaplasia and few mitoses
Acinic cell carcinoma
44
Diseases of Esophagus
1. Atresia and Fistulas
Presents soon after birth
Atresia: A segment of esophagus represented by
only a thin, non canalized cord, connected proximally
with a blind pharyngeal pouch and distally to a pouch
leading to the stomach
It is usually associated with fistula to the bronchus or
trachea
Other associated organ malformations: hepatic,
panreastic
Esophagus
Congenital anomalies
Atresia and fistula
A. Blind upper and lower esophageal segment
B. Fistula between blind upper segment and
trachea
C. Blind upper segment ,fistula between blind
lower segment and trachea
D. Blind upper segment only
E. Fistula between patent esophagus and
trachea
Type C is the commonest form
Tracheoesosphageal malforma.
48
Stenosis- fibrous thickening of the esophageal
wall with atrophy of the muscularis
Fibrous thickening of the esophageal wall
Most esophageal stenosis are acquired
Mucosal webs - semicircumferential
protrusions of the mucosa into the esophageal
lumen
Rings - concentric plates of tissue protruding in
to the lumen.
Lesions associated with motor dysfunction
Achalasia
motor dysfunction: failure to relax distal
esophageal sphincter => proximal dilatation
characterized by
Aperstalisis
Partial or incomplete relaxation of the LES
Increased resting tone of the LES
Pathogenesis of primary achalasia is poorly
understood
Achalasia
Secondary achalasia may arise in Chagas disease
in which Trypanosoma cruzi causes destruction of
the myenteric plexus
There will be progressive dilation of the
esophagus above the level of LES
Myenteric ganglia are usually absent from the
body of esophagus
Usually manifest in young adult hood
Achalasia
Classic clinical symptom is progressive dysphagia
Regurgitation and aspiration may occur
In about 5%, possibility of developing SCC
Other complications include
candidal esophagitis
diverticula and
aspiration with pneumonia
Hiatal hernia
characterized by separation of the diaphragmatic
crura and widening of the space between the
muscular crura and esophageal wall
Two patterns
Sliding
constitutes 95% of the cases
protrusion of the stomach above the diaphragm creating
a bell shaped dilation
Paraesophageal
a separate portion of the stomach usually along the
greater curvature enters the thorax
SSx: Heartburn; ulceration,
bleeding, perforation
Diverticula
An outpouching of the alimentary tract that
contains all visceral layers
False diverticulum is an outpouching of mucosa
and submucosa only
Typical symptoms are dysphagia ,regurgitation
and a mass in the neck
Aspiration with resultant pneumonia is a
significant risk
True eosophageal diverticula are usually
discovered later in life
Zenker diverticulum
Above the UES
Cricopharyngeal motor dysfunction
Traction diverticulum
Midpoint of esophagus
Scarring from mediastinium (eg.Tuberculosis
Epiphrenic diverticulum
Above the LES
incoordination of peristalsis and LES relaxation
Laceration (Mallory-Weiss syndrome)
longitudinal tears in the esophagus at the
esophagogastric junction
Believed to be a consequence of severe
retching
Occur most commonly in alcoholics
Laceration (Mallory-Weiss syndrome)
May reach several centimeters in length
Tears may involve only the mucosa or may
penetratre deeply enough to perforate the wall
Account for 5-10% of upper GI bleeding
Boerhaave syndrome is rupture of the
esophagus and is a rare and catastrophic event
Esophageal Varices
Tortuous dilated veins lying primarily within the submucosa of
the distal esophagus and proximal stomach
Cause: portal hypertension - cirrhosis, hepatic schistosomiasis
etc.
Clinical features
Usually produce no symptoms until they rupture
When they rupture => Massive hematemesis
Most important cause of cirrhosis associated deaths
Esophagitis
Inflammation of esophageal mucosa
Cause: chemical, physical, biologic agents
1. Reflux esophagitis
Reflux of gastric contents into the lower esophagus
Causes: Decreased efficacy of esophageal anti-reflux
mechanisms
Sliding hiatal hernia
Inadequate clearance of refluxed material
Delayed gastric emptying
reduction in the reparative capacity of the esophageal mucosa
Reflux esophagitis
Morphology
Simple hyperemia and edematous swellings
Histology
Presence of inflammatory cells (polymorphs) in the
squamous layer
Bazal zone hyperplasia
Elongation of lamina propria papillae with congestion
Clinical features
Largely limited to adults over age 40
Dysphagia, heartburn, regurgitation (vomitting),
hematemesis, melena (tarry stool due to presence of blood)
Consequences: bleeding, ulceration, stricture, Barretts
esophagus
Reflux esophagitis
63
Epidemiology of GERD and Barretts oesophagus
increasing gastro-oesophageal reflux disease (in the UK and USA at least)
risk factors for reflux disease:
male
middle age
white
overweight
alcohol
smoking
family history
Barretts esophagus
Def.: Glandular metaplasia after longstanding gastro-esophageal
reflux
Occurs in up to 10% of patients with GERD
Most important: risk factor for esophageal adenocarcinoma
Two criteria for diagnosis
Endoscopic evidence of columnar epithelial lining above
the gastroesophageal junction
Histologic evidence of intestinal metaplasia in the biopsy
specimen from the columnar epithelium
Morphology
Red, velvety mucosa between the smooth, pale pink
esophageal mucosa and the light brown gastric mucosa
Definitive diagnosis made when columnar mucosa
contains intestinal goblet cells
Clinical features
Most patients between 40 and 60
Ulceration, bleeding, stricture
Development of adenocarcinoma
Baretts epithelium
70
Infectious and chemical esophagitis
Causes:
Ingestion of mucosal irritants
Cytotoxic anticancer therapy
Viral infection HSV, CMV
Fungal infection- candidiasis, mucormycosis
Uremia in renal failure
Morphology
Severe acute inflammation
Superficial necrosis
Ulceration with granulation tissue
Clinical features
Esophagus infection most often occurs in
immunosuppressed
Chemical injury in children is accidental but in adults is
suicidal attempt
These images demonstrate three types of
infective oesophagitis.
73
Squamous cell carcinoma
Occur in adults over 50
Has male preponderance
Has higher incidence in Iran, China, SA
Blacks
Risk Factors for SCC of the Esophagus
Esophageal Disorders
Long-standing esophagitis
Achalasia
Plummer-Vinson syndrome (esophageal webs, microcytic hypochromic anemia, atrophic
glossitis)
Life-style
Alcohol consumption
Tobacco abuse
Hot beverage & foods
Dietary
Deficiency of vitamins (A, C, riboflavin, thiamine, pyridoxine)
Deficiency of trace metals (zinc, molybdenum)
Fungal contamination of foodstuffs
High content of nitrites/nitrosamines
Genetic Predisposition
Racial predisposition
Tylosis (hyperkeratosis of palms and soles)
Squamous cell carcinoma
About 20% are located in the upper third,
50% in the middle third, and 30% in the lower third
Three morphologic patterns are described
Protruded (60%)
polypoid exophytic lesion
Flat (15%)
a diffuse infiltrative form that spreads within the wall of
the esophagus causing thickening , rigidity and narrowing
Excavated (25%)
a necrotic cancerous ulceration that excavates deeply into
surrounding structures
79
Squamous cell carcinoma
Most are moderately to well differentiated
Local extension into adjacent mediastinal structures
occur early
Tumors in the upper third metastasize to cervical
lymph nodes
Those in the middle to mediastinal , paratracheal and
tracheobronchial nodes
Those in the lower third most often to gastric and
celiac groups of nodes
Clinical features
Dysphagia, progressive:
Dificulty to solid diets
Difficulty to liquid diets
Obstruction
Extreme weight loss
Hemorrhage and sepsis following ulceration
Aspiration:
Food stasis
Tracheosophgeal fistula
Lymph node metastases significantly reduces five year
survival rate
Adenocarcinoma
Increasing in incidence
Associated with Barrett esophagus
Usually located in the distal esophagus and may
invade the adjacent gastric cardia
May develop nodular masses or may exhibit diffusely
infiltrative or ulcerative features
Histologically most are mucin producing glandular
tumors
Adenocarcinoma
Majority arise from the Barretts mucosa
Life time risk for cancer development in Barretts is 10%
Usually located in distal esophagus
Most are over age 40
More common in men and whites
Manifestation: Dysphagia, weight loss, bleeding, chest
pain, vomiting
Prognosis is poor like other esophageal cancers
Transition from Barrett esophagus to adenocarcinoma
Baretts:dysplasia &
carcinoma
87
Rx and Px 0f esophageal cancers
Radiation
Postsurgical
Bezoars
Hypertrophic gastropathy
Gastric varices
Tumors of the stomach
Benign tumors
Polyps any nodule or mass that projects above the
level of the surrounding mucosa
Greater than 90% are of hyperplastic nature
5-10% are adenomas which are true neoplasms
Inflammatory fibroid polyp
Adenoma contains proliferative dysplastic epithelium
and thereby has malignant potential
Can be sessile or pedunculated
Gastric carcinoma
90-95% of malignant tumors of the stomach
Next in order are lymphoma (4%), carcinoids (3%)
and stromal tumors(2%)
Incidence varies widely being particularly high in
countries like Japan, Chile, China. .
M:F 2:1
Three major factors are thought to affect the
genesis of gastric cancer
Environmental-
infection by H.pylori, Diet (lack of refrigration,
consumption of preserved , smoked and salted
foods , lack of fresh fruit), cigarette smoking
Host factors
chronic gastritis, infection by H. pylori ,partial
gastrectomy, gastric adenomas , Barrett esophagus
Genetic
blood type A, family history, familial gastric
carcinoma
Morphology of Gastric carcinoma
Location
Pylorus and antrum (50-60%), cardia 25%, remaining in
the body and fundus
Lesser curvature is involved in about 40% and greater
curvature in 12%
Gastric carcinoma can be classified on the basis of
Depth of invasion
Macroscopic growth pattern
Histologic subtype
Gastric carcinoma
Depth of invasion
Early carcinomas lesion confined to mucosa and
submucosa
Advanced carcinomas that has extended below
the submucosa into the muscular wall
Macroscopic growth pattern
Exophytic
Flat or depressed
Excavated
Early Carcinoma
Advanced carcinoma
Morphologic types of
Carcinoma Stomach
Fungating
Ulcerating
Diffuse
Gastric Ca: Linitis plastica
Gastric carcinoma
Histologic subtype
Intestinal type
composed of neoplastic intestinal glands resembling
those of colonic adenocarcinoma
Diffuse type
composed of gastric type mucus cells which do not
form glands but permeate the wall as scattered
individual cells or clusters
These cells contain abundant mucin and form signet
ring configuration
Gastric carcinoma ..ctd
For obscure reasons gastric carcinomas frequently
metastasize to supraclavicular LN (Virchows node)
A notable site of visceral metastasis is to one or both
ovaries - Krukenberg tumor
Sister Mary Joseph nodule: The tumor can also
metastasize to the periumblical region
Clinical feature
Wt. loss , abdominal pain ,anorexia ,vomiting ,
altered bowel habit , anemia , hemorrhage ,
dysphagia . .
Less common gastric tumors
Gastric lymphoma
represent 5% of all gastric malignancies
related to H. Pylori
GI neuroendocrine cell tumors ( carcinoids)
Mesenchymal tumors
Leiomyoma , leiomyosarcoma , . .
GI stromal tumors (GIST)
Small and Large intestines
Congenital anomalies
Duplication
Malrotation
Omphalocele failure of formation of
abdominal musculature with herniation of
abdominal contents into a membraneous sac
Gastroschisis portion of the abdominal wall
fails to form altogether with extrusion of the
intestine
Atresia and stenosis
Meckel Diverticulum
- failure of the vitelline duct ,which connects the lumen
of the developing gut to the Yolk sac produce a Meckel
Diverticulum
- is a true diverticulum and lies usually 85cm from the
ileocecal valve
- heterotopic rests of gastric mucosa (or pancreatic
tissue) are found in about 50%
- occur in 2% of the population but most remain
asymptomatic
- when peptic ulceration occurs in the small intestinal
mucosa adjacent to the gastric mucosa bleeding occur
A
C
Congenital aganglionic Megacolon
(Hirschsprung disease)
Characterized by the absence of ganglionic
cells in large bowel leading to functional
obstruction and colonic dilation proximal to
the affected segment
Histologically there is absence of ganglionic
cells in the muscle wall(Auerbach plexus) and
submucosa (Meissner plexus)
Most cases involve the rectum and sigmoid only
Clinical features
M:F 4:1
Neutrophilic infiltration
Clinical features
Ingestion of preformed bacterial toxins
symptoms develop within hours ,explosive
diarrhoea, acute abdominal distress . . .
M:F 10:1
Ulceration