Fibromuscular tube, 25 cm long ; connects
pharynx and stomach
Extends from cricopharyngeal sphincter in
pharynx (level of C6) to lower esophageal
sphinchter at GE junction (T11/T12), 2 cm of this
tube lies below the diaphragm.
Main purpose is to propel food from pharynx to
stomach via peristalsis
Cervical (cricoid cartilage to suprasternal notch,
3 cm long, 15 cm from incisors)
Upper thoracic (suprasternal notch to tracheal
bifurcation, 6 cm long, 18 cm from incisors)
Mid-thoracic (tracheal bifurcation to
diaphragmatic hiatus, 8 cm long, 24 cm from
Lower thoracic and abdominal (8 cm long, 32 cm
Normal histology of esophagus
Mucosa: nonkeratinized stratified squamous
lamina propria: fibrovascular connective tissue
between epithelium and muscularis mucosae
Submucosa: submucosal glands lined by
mucinous cells that produce acid mucin
Muscularis propria: inner circular and outer
Adventitia: loose connective tissue
Defined as epithelial damage and inflammation of
Most common cause
– Gastroesophageal reflux disease (reflux of
gastric contents into lower esophagus)
Infectious- less common cause
Type of ESOPHAGITIS
Chemical (corrosive) esophagitis
– alcohol, corrosive acids or alkalis, excessively hot
fluids, and heavy smoking, medicinal pills, cytotoxic
– Viral: CMV, herpetic, HPV, HIV
– Fungal: Candida, aspergilus
– Bacterial: rare, tuberculosis
The morphology of chemical and infectious esophagitis
varies with etiology.
Dense infiltrates of neutrophils are present in most cases
but may be absent following injury induced by chemicals,
which may result in necrosis of the esophageal wall.
Pill-induced esophagitis frequently occurs at the site of
strictures that impede passage of luminal contents.
CMV - cytomegalovirus esophagitis
Usually immunocompromised patients
Up to 30% of AIDS patients have CMV
Gross: punched out mucosal ulcers with normal surrounding
Micro: Basophilic cytoplasm often has coarse intracytoplasmic
Prominent intranuclear basophilic inclusions surrounded by clear
Macrophage aggregates in perivascular distribution
Herpes simplex esophagitis
Usually an opportunistic infection in
immunosuppressed / AIDS patients
Gross: shallow vesicles and ulcers
Ulcers contain necrotic debris and exudate with
neutrophils; viral inclusions are present in
multinucleated squamous cells (Cowdry type A)
Reflux of gastric contents into the lower
esophagus is the most frequent cause of
The associated clinical condition is termed
gastroesophageal reflux disease (GERD).
Reflux of gastric juices is central to the development of
mucosal injury in GERD.
In severe cases, reflux of bile from the duodenum may
exacerbate the damage.
Conditions that decrease LES tone or increase abdominal
pressure contribute to GERD:
– alcohol and tobacco use
– obesity, CNS depressants, pregnancy, hiatal hernia,
delayed gastric emptying.
Endoscopy: linear ulcers at distal esophagus,
often with exudate; also erythema or edema.
Gross: severe cases have hyperemic mucosa
with focal hemorrhage
Micro: inflammatory cells in epithelial layer
(eosinophils, neutrophils, lymphocytes); basal
cell hyperplasia, elongation of lamina propria
papillae; ballooned squamous cells, vascular
The most common clinical symptoms are
heartburn, dysphagia,nausea vomitting.
Severity of symptoms is NOT related to
histology; pain may be mistaken for myocardial
Treatment: proton pump inhibitors or H2
Complications: esophageal ulceration,
hematemesis, melena, stricture development,
and Barrett esophagus.
Barrett Esophagus, IMP
Definition: condition where distal squamous
mucosa of esophagus is replaced by metaplastic
columnar epithelium as a response to chronic
Appears to be irreversible
Barrett esophagus is a complication of chronic
Barrett esophagus is a pre-malignant condition
for esophageal adenocarcinoma.
Causes: usually chronic GERD
Almost always associated with
– sliding hiatal hernia
– esophageal stricture
– bile/pancreatic juice reflux
– peptic ulceration, decreased resting pressure
of lower esophageal sphincter
Gross: patches of red, velvety mucosa extending
upward from the GE junction.
This metaplastic mucosa alternates with residual
smooth, pale squamous (esophageal) mucosa
and interfaces with light-brown columnar
(gastric) mucosa distally.
– Long-segment: Barrett’s mucosa extends 3
cm or more
– Short-segment: Barrett’s mucosa extends less
than 3 cm
Micro: esophageal squamous epithelium is
replaced by columnar epithelium of intestinal
type (stomach, small bowel, colon) with goblet
Lamina propria is fibrotic with mild chronic
Muscularis mucosae may be thickened
When dysplasia is present, it is classified as low
grade or high grade.
High grade dysplasia: 15-50% risk of invasive
Low grade dysplasia: may progress to high
grade dysplasia or carcinoma for up to 10 years
Squamous cell carcinoma
Half of squamous cell carcinomas occur in the middle third
of the esophagus
Highest incidence in northern Iran, northern China, and
other developing countries
Usually men (75%) age 50+ years; more common in blacks
(4:1) in US
Mutations of several tumor suppressor genes, including
p53 and p16,EGFR gene.
Risk factors for SQC
Long-standing esophagitis, achalasia
Plummer-Vinson syndrome- triad of esophageal webs,
microcytic hypochromic anemia,dysphagia, atrophic
Alcohol consumption, tobacco abuse
Deficiency of vitamins (A, C, riboflavin, thiamine,
Deficiency of trace metals (zinc, molybdenum)
Fungal contamination of foodstuffs
High content of nitrites/nitrosamines
Squamous cell carcinomas are usually preceded
by a long prodrome of mucosal epithelial
dysplasia followed by carcinoma in situ and,
ultimately, by the emergence of invasive cancer.
Sheets or islands of large polygonal malignant cells with
pink cytoplasm and distinct cell borders.
Presence of keratinization and/or intercellular bridges in
the form of squamous pearls or individual cells with
markedly eosinophilic dense cytoplasm
Superficial squamous cell carcinoma
confined to mucosa and
submucosa regardless of lymph node
Intramucosal tumors have 5% lymph node
involvement vs. 35% for submucosal
5 year survival is 85% without vs. 40%
with nodal involvement
Odynophagia (pain on swallowing).
Extreme weight loss and debilitation result from
both impaired nutrition and effects of the tumor
Adenocarcinoma of esophagus
40-50%% of primary esophageal cancers
increasing incidence over past 20 years for unknown
Age 50+ years; 80% men
95% arise in setting of Barrett’s esophagus
Risk factors: alcohol or tobacco use, positive family
Molecular studies suggest that the progression of Barrett
esophagus to adenocarcinoma occurs over an extended
period through the stepwise acquisition of genetic and
Barrett metaplasia- progression to dysplasia and invasive
Mutation of p53 and retinoblastoma gene are present
Alterations in HER-2/NEU gene.
Usually occurs in the distal third of the
Gross: Initially appearing as flat or raised
patches on an otherwise intact mucosa, they
may develop into large nodular masses or show
deeply ulcerative or diffusely infiltrative features.
Micro: most tumors are mucin-producing
glandular tumors showing intestinal-type
features. Barrett esophagus is frequently present
adjacent to the tumor
Less frequently tumors are composed of
diffusely infiltrative signet-ring cells.
Acute Gastritis/ Active gastritis
Acute gastritis is a transient inflammatory
process of gastric mucosa.
It may be asymptomatic or cause variable
degrees of epigastric pain, nausea, and vomiting.
May be accompanied by local hemorrhage or
(NSAIDs), particularly aspirin
Excessive alcohol consumption
Severe stress (e.g., trauma, burns, surgery)
Ischemia and shock
Suicidal attempts, as with acids and alkali
Mechanical (e.g., nasogastric intubation)
Increased acid production with back diffusion
Decreased bicarbonate production and direct
Gross: Edema and hyperemia with occasional hemorrhage.
Micro: Scattered intraepithelial neutrophils or neutrophils
within mucosal glands.
With more severe mucosal damage, erosions and
An erosion: loss of the superficial epithelium (epithelial
sloughing), generating a defect in the mucosa that is
limited to the lamina propria.
ACUTE GASTRIC ULCERATION
Stress ulcers are most common in patients in
ICU with shock, sepsis, or severe trauma.
Curling ulcers: Ulcers occurring in the proximal
duodenum and associated with severe burns or
Cushing ulcers: Gastric, duodenal, and
esophageal ulcers arising in persons with
intracranial disease. It carry a high incidence of
Acute ulcers are shallow and punched out, size:
up to 1 cm in diameter.
The ulcer base is frequently stained brown to
black by acid digestion of extravasated blood
The gastric rugal folds are essentially normal,
and the margins and base of the ulcers are not
Micro: sharply demarcated, with essentially
normal adjacent mucosa, blood into the mucosa
Healing with complete re-epithelialization
(without scar) occurs after the injurious factors
Complications of Gastric Ulcers
– Bleeding (hematemesis and or malena)
Pyloric stenosis, secondary to edema or
– Penetration into neighboring viscera
– Malignant ulcer