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Pathology of the upper GIT
Dr A. Barbour, Discipline of Pathology. Copyright University of Adelaide 2009.
Causes of dyspepsia/indigestion
Upper gastrointestinal
• Chronic peptic ulcer
• Acute and chronic gastritis
• Gastro-oesophageal reflux and oesophagitis
• Hiatus hernia
• Tumours: oesophageal, gastric
Other e.g. gall stones
Oesophagitis
Gastro-oesophageal reflux
• Pathogenesis/risk factors: decreased efficiency of lower oesophageal sphincter, increased intra-abdominal pressure,
sliding hiatus hernia
• Symptoms: heartburn, regurgitation
• Complications: ulceration and bleeding (acute or chronic), fibrosis and stricture, development of Barrett’s oesophagus
• Barrett’s oesophagus
• Metaplasia of lower oesophageal stratified squamous epithelium to glandular epithelium: gastric cardiac and
intestinal types
• Caused by gastro-oesophageal reflux
• Risk of glandular dysplasia and carcinoma
Infective oesophagitis (e.g. fungal, Herpes simplex) in debilitated/immunocompromised
Irritant ingestion
Hiatus hernia
• Herniation of part of stomach above diaphragm
• 2 main types: sliding and paraoesophageal
• Often asymptomatic but indigestion/heartburn may occur
Gastritis
Acute
• Risk factors: trauma, burns, shock, raised ICP, excessive alcohol, heavy use of NSAIDs, oral corticosteroids, other
• Pathogenesis: toxic or ischaemic injury to mucosa
• Acute mucosal inflammation, widespread petechial mucosal erosions with haemorrhage
• Abdominal discomfort
• Acute ulcers (usually multiple) may form and bleed or perforate
Chronic
• Environmental/multifocal
• Risk factors: mainly H. pylori
• Antrum +/- more proximal stomach
• Common, often asymptomatic
• Chronic mucosal inflammation with many lymphocytes +/-germinal centres, frequently also with neutrophils (active)
• May -> glandular atrophy, intestinal metaplasia and dysplasia -> intestinal type of gastric adenocarcinoma
• Autoimmune
• Fundus and body
• Uncommon
• May -> glandular atrophy, intestinal metaplasia and dysplasia -> intestinal type of gastric adenocarcinoma
• Causes pernicious anaemia
• Other specific types: Crohn’s disease, infective
Chronic peptic ulcer
• Predominantly middle aged and elderly
• Affects up to 10% of adult population in western countries
• Arises due to imbalance between action of gastric acid and mucosal defence - main problem is impaired mucosal defence
• Mucosal defence mechanisms include intact epithelium, mucus and bicarbonate secretion, good mucosal blood flow,
prostaglandin synthesis
• Histologically get necrotic debris on surface, with underlying acute inflammation, granulation tissue, chronic
inflammation and scarring
•Sites
• Gastric
• Usually antrum or pylorus
• Usually single
• 70% assoc. with H. pylori: H. pylori produce a variety of substances that damage the gastric epithelium and
the protective effect of the mucus, and lead to inflammation, thus weakening the mucosal defence
mechanisms against acid. Most others related to NSAIDs that inhibit mucosal prostaglandin synthesis.
Cigarette smoking, genetic factors may play a role
• Duodenal
• Usually in first part
• Males > females
• Nearly100% associated with H. pylori: pathogenesis uncertain, but may relate to enhanced gastric acid
secretion (though levels often not elevated) and accelerated gastric emptying -> reduced duodenal pH ->
gastric metaplasia and colonization with H. pylori that injures the epithelium. Cigarette smoking, genetic
factors may play a role
•Increased incidence in patients with cirrhosis
• Also in lower oesophagus, Meckel’s diverticulum
• Complications
• Acute and chronic bleeding
• Penetration into pancreas
• Perforation into peritoneal cavity
• Gastric outlet obstruction related to scarring
Tumours
• Oesophageal
• Squamous cell carcinoma
• Commonest type
• Male > female
• Risk factors mainly smoking and alcohol in western countries, achalasia, dietary carcinogens in certain areas of
high incidence (e.g. China)
• Polypoid fungating, flat or deeply ulcerative lesions
• Presents late, generally poor prognosis
• Adenocarcinoma in lower oesophagus related to dysplasia in Barrett’s oesophagus
• Other
• Gastric
• Adenocarcinoma
• Intestinal/localised type
• Risk factors: diet (carcinogens e.g. nitrosamines), H. pylori, smoking, alcohol, autoimmune gastritis, other
• Pathogenesis: chronic gastritis -> mucosal atrophy with intestinal metaplasia -> dysplasia
• Especially common in certain parts of the world e.g. Japan
• Fungating or polypoid mass or ulcerating lesion
• Generally poor prognosis unless early gastric carcinoma - confined to mucosa or submucosa regardless of
lymph node involvement
• Diffuse/signet ring/linitis plastica type
• Widely infiltrates stomach
• Risk factors unknown
• Poor prognosis
• Lymphoma: MALT and other types
• Gastrointestinal stromal tumour
• Other
Helicobacter pylori
• 50% of adult population >50yrs in western countries
• Curved gram negative rods, found on the surface of the gastric epithelium
• Commonly causes active chronic gastritis: lymphoid infiltrate with lymphoid follicles in mucosa, also neutrophil infiltrate
• Most asymptomatic
• Risk factor for
• Chronic peptic ulceration
• Mucosal atrophy with intestinal metaplasia -> dysplasia -> gastric intestinal type adenocarcinoma
• Gastric MALT lymphoma
Acute upper GI bleed
• Mallory-Weiss tear
• Oesophageal varices
• Lower oesophagus
• Develop secondary to portal hypertension, usually as a result of cirrhosis
Disturbed liver architecture in cirrhosis -> impaired blood flow through liver -> portal hypertension -> dilatation of
normal porto-systemic venous anastomoses around lower oesophagus
Acute or chronic ulceration in oesophagitis
Chronic peptic ulcer
Acute gastric ulcers/erosions assoc. with acute gastritis
Malignancy uncommonly
Others
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Dysphagia
• Physical blockage/narrowing
• Stricture
• Scarring in reflux oesophagitis, post irradiation, corrosive ingestion
• Scleroderma
• Webs and rings
• Congenital abnormalities: atresia and fistulae, stenosis
• Tumour:
• In oesophagus or gastric cardia
• Extrinsic compression of oesophagus by tumour
• Neuromuscular
• Achalasia: failure of relaxation of lower oesophagus with proximal dilatation
• Autonomic neuropathy
• Cranial nerve problems