Basic pathology for medical student

1. Manasanan Raveesunthornkiat, MD
7/12/2012

2. OBJECTIVES
• Recall – embryology, anatomy, physiology
• Learn
– What diseases?
– What signs and symptoms?
– How to diagnose?
– How to treat?

5. UES
Upper
1/3
Squamous
Middle
1/3
Lower
1/3
LES
Gastric

8. • Dysphagia
• Heartburn (pyrosis)
• Regurgitation
• Hematemesis

9. Structure Function

11. • Congenital
anomalies
Clinical presentation
– Drooling
– Aspiration
– Suffocation
– Pneumonia

13. • “Failure to relax”
• Uncertain etiology
• Risk for squamous cell
carcinoma
Clinical presentation
– Young adulthood
– Progressive dysphagia
– Nocturnal regurgitation
– Aspiration
Pathology
Progressive dilation above the LES
Thickened muscular wall
Normal or ulcerated mucosa
Absent of myenteric ganglia at the body

14. Manometer
• Aperitalsis
• Partial or incomplete relaxation
of the LES with swallowing
• Increased resting tone of the LES
Manometry

16. Complication of portal hypertension

17. Pathology
• Dilated submucosal veins
• Distal esophagus, proximal
stomach
Clinical features
• Masssive hematemesis
(when rupture)

18. • Endoscopic management
• Surgical management
• Supportive management
– Temporary stop bleeding
– Blood transfusion
– Protect airway
• Treated underlying diseases

21. Dysphagia Odynophagia
Upper Retrosternal
GI bleeding pain
Fistula Perforation Sepsis

22. Esophagitis
Infection Idiopathic Mechanical
Virus Traumatic Radiation Chemical
Bacteria Reflux
Mycobacteria Medication
Corrosive
Fungus
agents

23. • especially in immunocompromised persons
• acute-onset nausea and vomiting
• Odynophagia Herpes simplex (HSV)
• Fever Cytomegalovirus (CMV)
• retrosternal pain Epstein-Barr (EBV)
• GI bleeding Human papilloma (HPV)
• Spontaneous esophageal perforation.

25. Pathology
Punched-out ulcers
Nuclear inclusions in
degenerating
epithelial cells

26. Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus strains

27. Esophageal tuberculosis
Acid fast stain positive (acid fast bacili)

28. Most common  Candida species
Others:
Histoplasma, Paracoccidioides, Trichosporon, Asperg
illus, Cryptococcus, Coccidioides, Fusarium, Blastom
yces, and Mucor
Adherent gray-white pseudomembranes

29. Narrowing site
• Doxycycline
• Emepromium Bromide
• KCL
• Quinidine
(forms mss-like lesion)
• Iron sulphate
• NSAIDs
• Alendronate

30. strong corrosive chemical substances
(alkalis or acids)
Extent of the injury depends on
- Type --alkali > acid
- Amount
- Concentration
- Physical state
- Exposure duration
Complications
• Stenosis
• Perforation
• Mediastinitis
• Pneumonitis

31. Pathology: Coagulative necrosis
Three grades (Gumaste and Dave)

32. • Symptomatic treatment
– Improve patient status
• Definitive treatment
– Antibiotics, antiviral, antifungal drugs
• Prevent complication
– Stricture
– Rupture
• Prevent recurrence

33. Adults > 40 yr
Symptoms
Dysphagia
Heart burn

34. A multifactorial disorder
A lower mean LES resting pressure Increased gastric volume/ pressure
Muscle weakness after meals
Scleroderma-like diseases pyloric obstruction
Myopathy gastric stasis
Pregnancy during acid hypersecretion states
Smoking Obesity
Medications Pregnancy
Surgical damage to the LES Ascites
Esophagitis tight clothes
Transient relaxation of LES
Inadequate or slowed clearance of refluxed material
Delayed gastric emptying
Reflux of both acid and alkaline secretions

35. • GI tract consequences
– Bleeding, ulceration
– Stricture
– Barrett esophagus
Extra-esophageal manifestations

36. 24-hour pH study
Endoscopy with Biopsy

37. Gross: Hyperemia
Microscopic
• Basal zone hyperplasia
• Elongation of lamina
propria papillae
• Inflammatory cells

38. Reflux
Heal
Stricture
Barrett
5%
Ulceration
Injury
Inflammation
Epithelial proliferation
Adenocarcinoma

39. Life style • Positioning
modification • Diet
Medication • Acid suppression therapy
Prevent • Barette esophagus
complication • Esophageal stricture
Treatment of
• Surgery
underlying diseases

40. • Intestinal metaplasia
• Complication of long-
standing GERD
• 10% of GERD patients
• Most important risk
factor for esophageal
adenocarcinoma

42. Intestinal metaplasia (Barrett)  dysplasia  adenocarcinoma

43. ก. ?
ข.
ค.
ง.

44. • Ulceration
• Perforation
• Stricture
• Luminal mass
• Invasion to adjacent
organs

48. Squamous cell carcinoma
Adenocarcinoma Upper-lower esophagus
Lower esophagus

50. • Smoking 5- to 10-fold. • Barette esophagus
• Alcohol
• Hot beverage
• Plummer-Vinson
syndrome, celiac sprue and
achalasia
• Chronic esophagitis
• Chemical injury with
esophageal stricture 20-40 yr
• HPV infection
• Webs, rings and diverticula

52. MRI

53. • 5-year survival 10%
• Depend on staging

54. • Treatment modality
– Surgery
– Chemotherapy
– Radiation
• Curative care
– Complete resection
• Palliative care
– Improve quality of life
– End of life care

57. Benign smooth muscle tumor
Submucosal mass

58. Reference
• Abbas K and Aster F, Robbin and Cotran
pathologic basis of disease. 8th edition. Saunders
Elsevier, Philadelphia, 2010
• Rubin R and Strayer DS, Rubin’s pathology:
clinicopathologic foundations of medicine .6th
edition. Lippincott Company, China, 2012
• Noffsinger AE, Stemmermann GN, Lantz PE and
Isaacson PG. Gastrointestinal pathology an atlas
and text. 3rd edition. Lippincott
Company, Philadelphia, 2008