STEPTRACKERGASTROINTESTINAL | PATHOLOGY | HIGH-YIELD REVIEW

Esophagus II — Esophagitis, Barrett & Cancer

Inflammation of the esophagus from acid, allergy, infection or pills — and the two carcinomas that follow different roads.

FOCUS ON
GERD → Barrett (intestinal metaplasia with goblet cells) → adenocarcinoma of the distal third. SCC is upper/middle, worldwide, driven by smoking, alcohol, hot drinks, achalasia and caustics. Know the infectious esophagitis look-alikes and eosinophilic esophagitis (rings + furrows).
DISORDER
MECHANISM · CAUSE
FEATURES
CLUE
GERD
Transient LES relaxation / low LES tone: alcohol, tobacco, obesity, fatty food, caffeine, pregnancy, hiatal hernia, scleroderma
Heartburn, regurgitation, nocturnal cough or asthma, hoarseness, dental erosion
Basal cell hyperplasia, long papillae, eosinophils/neutrophils · strictures, Barrett
Eosinophilic esophagitis
Allergic (food antigens), atopic patients; young men
Dysphagia, food impaction; > 15 eosinophils/hpf; rings ("trachealization") + linear furrows
Elimination diet, swallowed topical steroids, dupilumab
Candida esophagitis
Most common infectious cause; HIV, steroids
White pseudomembranes; odynophagia
Yeasts and pseudohyphae
HSV esophagitis
HSV-1 in the immunocompromised
Small punched-out ulcers
Multinucleated cells with intranuclear inclusions at the ulcer edge
CMV esophagitis
CMV in AIDS / transplant
Large, shallow, linear ulcers
Intranuclear + cytoplasmic inclusions in endothelial/stromal cells (ulcer base)
Pill & caustic esophagitis
Doxycycline, NSAIDs, bisphosphonates, KCl, iron · lye (alkali → liquefactive necrosis)
Odynophagia; caustic → strictures, later SCC
Take pills upright with water
Barrett esophagus
Chronic GERD → intestinal metaplasia: nonciliated columnar cells + goblet cells
Salmon-colored mucosa extending up from the GE junction
White men · surveillance; ablate dysplasia
Esophageal adenocarcinoma
Barrett → dysplasia → carcinoma; GERD, obesity, smoking
Distal third; most common type in the US/West
Spreads to celiac and gastric nodes
Esophageal SCC
Smoking, alcohol, very hot drinks, achalasia, Plummer-Vinson, caustic stricture, nitrosamines, tylosis
Upper/middle thirds; most common type worldwide (Asia, Iran, Africa)
In the US more common in Black men · cervical/mediastinal nodes
Esophageal cancer — presentation
Silent until advanced
Progressive dysphagia (solids → liquids), weight loss, odynophagia, hoarseness, cough (fistula)
Poor prognosis

Mechanism — reflux to adenocarcinoma

Acid + bile reflux
→
EsophagitisSquamous injury
→
Intestinal metaplasiaBarrett (goblet cells)
→
Low → high-grade dysplasiaTP53 loss
→
AdenocarcinomaDistal third

Adenocarcinoma vs SCC

FEATURE
ADENOCARCINOMA
SQUAMOUS CELL
Location
Distal third
Upper and middle thirds
Precursor
Barrett esophagus
Squamous dysplasia
Risks
GERD, obesity, smoking
Smoking, alcohol, hot drinks, achalasia, caustics
Who
White men (West)
Worldwide; Black men (US)
Nodes
Celiac, perigastric
Cervical, mediastinal

How it's tested

COMMON CONFUSIONBarrett requires goblet cells (intestinal metaplasia). Gastric-type columnar cells without goblet cells don't count on the exam.
THE TRAPHSV ulcers are small and punched-out with inclusions at the edge. CMV ulcers are large and linear with inclusions deep in the base — biopsy the base for CMV.
YOUR APPROACHOdynophagia → infection or pill. Dysphagia + atopy → eosinophilic. Chronic reflux → look for Barrett. Mass → location and risk factors decide the type.

If you see… think…

Chronic heartburn, salmon mucosa, goblet cells → Barrett esophagus
Barrett with high-grade dysplasia → endoscopic ablation or resection
Obese White man with GERD and a distal mass → adenocarcinoma
Mid-esophageal mass in a smoker who drinks very hot tea → SCC
Young atopic man, food impaction, rings and furrows → eosinophilic esophagitis
HIV patient with odynophagia and white pseudomembranes → Candida
Punched-out ulcers with multinucleated cells → HSV esophagitis
Large linear ulcers with endothelial inclusions → CMV esophagitis
Odynophagia after doxycycline taken at bedtime → pill esophagitis
Lye ingestion in childhood, dysphagia as an adult → caustic stricture → SCC risk