Diseases of Digestive System

Esophagitis
Reflux esophagitis: A inflammation of
esophagus caused by long-term
gastroesophageal reflux
Morphology:
mild esophagitis- simple hyperemia
without histologic abnormality
severe esophagitis- confluent epithelial
erosion or total ulceration into
submucosa
 Histologic feature:
1. eosinophils, with or without neutrophils,
in the epithelial layer
2. basal zone hyperplasia
3. elongation of lamina propria papillae
Reflux Esophagitis
 Barrett Esophagus
Barrett esophagus is defined as the
replacement of the normal distal stratified
squamous mucosa by metaplastic
columnar epithelium containing goblet
cells. It is a kind of precancerous lesion.
Prolonged and recurrent
gastroesophageal reflux produces
inflammation and eventually ulceration of
the squamous epithelial lining
Morphology: Barrett esophagus
appears as a salmon-pink, velvety
mucosa between the smooth, pale
pink esophageal squamous mucosa
and the more lush light brown gastric
mucosa.
Microscopically, the esophageal
squamous epithelium is replaced by
metaplastic columnar epithelium.
Barrett esophagus
Barrett esophagus with intramucosal carcinoma
The normal structure of mucosa in body of
stomach
The normal structure of mucosa in antrum
 Gastritis
Gastritis is simply defined as
inflammation of the gastric mucosa.
No obvious lesion in submucosa,
muscular and serous layer.
Chronic gastritis is defined as the
presence of chronic mucosal
inflammatory changes leading
eventually to mucosal atrophy and
epithelial metaplasia.
 Chronic Gastritis
Type A-related to autoimmune, rare in
Chinese Location: body of stomach
Antibody to parietal cell (+), antibody
to intrinsic factor (+).
Type B-related to infection etc. factors.
Lesion location: antrum, pylori,
antrum&body, related term: chronic
antral gastritis, chronic pan-gastritis
 Etiology
Infection of Helicobacter pylori
Bile reflux
Long-term irritation of cigarette
smoking
Alcohol, drug
Superfial gastritis: inflammation (+),
atrophy of gastric glands (-)
Atrophic gastritis: inflammation (+),
atrophy of gastric glands (+)
 Morphology
A lymphocytic and plasma cell
infiltrate in the lamina propria,
occasionally accompanied by
neutrophilic inflammation. The
inflammation may be accompanied by
variable gland loss and mucosal
atrophy.
 Chronic gastritis:
Inflammation 1 2 3
Activation 0 1 2 3
Atrophy 0 1 2 3
Intestinal metaplasia 0 1 2 3
Atypical hyperplasia 0 1 2 3
Severe atypical hyperplasia predisposing
to malignant transformation
Chronic superficial gastritis
Chronic atrophic gastritis
 Peptic Ulcer
Ulcers are defined as a breach in the
mucosa of the alimentary tract that
extends through the muscularis
mucosae into the submucosa or
deeper. Peptic ulcers are chronic,
solitary lesion that occur in any portion
of the gastrointestinal tract exposed to
the aggressive action of acid-peptic
juices.
 Location:
Duodenum: globular portion 4
Stomach: antrum, lesser curvature 1
 Pathogenesis
The hypothesis: peptic ulcers are
induced by an imbalance between the
gastroduodenal mucosal defenses
and the countervailing aggressive
forces that overcome such defenses.
Damage of barrier function of gastric
and duodenal membrane
Digestion of gastric acid. No acid, no
ulcer
 Morphology
Gross: solitary, oval or round, 2.5cm
or less in diameter, sharply punched-
out margin, rugged folds of mucosa
radiate out from the ulcer like wheel
spokes, different depth: submucosa,
muscularis propria or entire wall
 Microscopically, the base of ulcer is
composed of four layers
(1) Exudative layer
(2) Necrotic layer
(3) Granulation tissue
(4) Fibrous scar
Chronic peptic ulcer: stomach
 Four complications:
(1) Bleeding: massive or occult
hemorrhage (usually in gastric ulcer)
(2) Perforation (usually in duodenal
ulcer)
(3) Pyloric obstruction
(4) Cancerous transformation of gastric
ulcer, <1%; Duodenal ulcer
extremely rare
 Clinical Feature
Epigastric gnawing, burning, or boring
pain, the pain tends to be worse at
night and occurs usually 1-3 hours
after meals during the day, the pain is
relieved by alkalis or food.
 Crohn Disease

Etiology unknown, autoimmunological,

systemic disease. Antibody to colon
membrane (+)
Location: usually in terminal ileum and
large intestine
 Morphology

Gross:
1. segmental, solitary, occasionally
multifocal-skip lesion
2. the sharp demarcation between diseased
bowel segments and normal intestine
3. involved membrane: edematous,
“cobblestone” appearance, serpentine
linear ulcer
4. the intestinal wall thickening and stricture
Crohn disease: caecum
Crohn disease: ileum
Crohn disease: ileum and ascending colon
 Microscopic examination:
1. transmural inflammation
2. cleaved ulcer
3. non-caseating granulomas
4. in diseased segments, the muscularis
mucosae and muscularis propria are
markedly thickened and fibrosis affects all
tissue layers
5. lymphoid aggregates scattered through
the various tissue layers, dilation of
lymphatics
Epithelioid granulomas of Crohn disease
 Ulcerative Colitis
Ulcerative colitis (UC) is an
ulceroinflammatory disease affecting
the colon but limited to the mucosa
and submucosa except in the most
severe cases. UC begins in the
rectum and extends proximally in a
continuous fashion, sometimes
involving the entire colon.
Etiology: unknown,
autoimmunological, inflammation
disease, with mainly intestinal
manifestations; Antibody to mucosa of
colon (+).
Location: only in the colon: rectum
and proximal extension
 Morphology
Gross: mucosa: diffuse hyperemia,
hemorrhage, numerous ulceration,
abscess.
Microscopically:
(1) a diffuse, predominantly mononuclear
inflammatory infiltrate in the lamina
propria at first, followed by infiltration of
neutrophils, lymph cells and eosinophilic
leukocytes. The collections of neutrophils
in crypt lumina form crypt abscesses
(2) The destruction of the mucosa leads to
outright ulceration, extending into the
submucosa.
(3) With remission of active disease,
granulation tissue fills in the ulcer craters,
followed by regeneration of the mucosal
epithelium and forms pseudopolyps.
Mucosal dysplasia may occur.
(4) Submucosal fibrosis and mucosal
architectural disarray and atrophy remain
Ulcerative colitis: acute form
Ulcerative colitis: chronic form
Ulcerative colitis with pseudopolyp
Ulcerative colitis: crypt abscesses
The most serious complication of UC
is the development of colon
carcinoma.
Clinical features: relapsing mucinous,
bloody and purulent stool, with less or
more extragastrointestinal
manifestations
Differential diagnosis of UC and CD
In UC, well-formed granulomas are
absent.
UC does not exhibit skip lesions.
The mucosal ulcers in UC rarely extend
below the submucosa, and there is little
fibrosis.
Mural thickening does not occur in UC and
the serosal surface is usually completely
normal.
Patients with UC are at greater risk for
carcinoma.
Chronic ulcerative colitis with a carcinoma arising
in the caecum
 Polyps of Colon
Finger or fungi-like protrusion of
mucosa due to proliferation of
epithelia
1. Non-neoplastic polyp
Inflammatory polyp (juvenile polyp)
hyperplastic polyp
melanin spots polyp
(Peutz-Jegher Syndrome)
Inflammatory polyp in large intestine
Hyperplastic polyp in colon
Melanin Spots Polyp in Small Intestine
Melanin Spots Polyp in Colon
2. Neoplastic polyp (adenomatous polyp)
Tubular adenomas (malignancy potential)
Villous (Papillary) adenomas (easy to
carcinoma)
Tubulovillous (Papillary-tubular)
adenomas
Familial multiple polyposis (high incidence
of carcinoma)
Benign tubular adenomatous polyps of the colon
Villous adenoma: rectum
Tubular Adenoma in Colon
Tubular Adenoma in Colon
Villous Adenoma in Colon
Villous Adenoma in Colon
Tubulovillous Adenoma in Colon
Tubulovillous Adenoma in Colon
Familial Adenomatous Polyposis
Carcinomas of esophagus, stomach
and colon
Predilection sites:
Carcinomas of esophagus: upper, middle,
lower strictures
Carcinomas of stomach: the lesser curvature
of the antropyloric region
Carcinomas of colon: rectum, sigmoid, cecum,
ascending colon
Gross: protrusive, ulcerative, infiltrative
Ulcerative adenocarcinoma of stomach
Leather bottle stomach (linitis plastica)
Polypoid adenocarcinoma of the colon
Ulcerative carcinoma of the colon
Adenocarcinoma of the rectum
Squamous cell carcinoma of the anus
 Histological types:
Squamous cell carcinoma
Small cell carcinoma
Adenocarcinoma: tubular, papillary,
mucinous, squamous cell carcinoma
(anal canal)
Squamous cell carcinoma of esophagus
Squamous cell carcinoma of esophagus
Squamous cell carcinoma of esophagus
Small cell carcinoma of esophagus
Papillary adenocarcinoma
Tubular adenocarcinoma
Tubular adenocarcinoma
Tubular adenocarcinoma infiltrating the
muscle wall
Signet-ring cell carcinoma of stomach
Signet-ring cell carcinoma of stomach
Signet-ring cell carcinoma
Mucinous adenocarcinoma
 Differential diagnosis between peptic
ulcer and ulcerative type of stomach
peptic ulcer ulcerative type of
stomach
Location antrum antrum
Diameter <2.5cm >2.5cm
Edge regular irregular
(heaped-up margin)
Acid more absent or little
Pain related to food persistent
Cachexia (-) (+)
 Etiology
Dietetic factors
Barrett esophagus
Helicobacter pylori infection
Gastric ulcer
Adenoma heredity
Inflammation