Oral Cavity & GI Tract

Upper Digestive Tract

Oral cavity

Esophagus

Stomach

Lower Digestive Tract

Small intestine

Large intestine

Rectum

Anus

Diseases of Teeth and Co

Caries

Gingivitis

Periodontitis

Oral Inflammatory Lesions

Aphthous ulcers

HSV

Candidiasis

Proliferative and Neoplastic Oral

Pyogenic granuloma

Fibroma

Leukoplakia

Erytroplakia

Squamous cell carcinoma

Disease of Salivary Glands

Xerostomia

Sialadentitis

Mucocele

Pleomorphic adenoma

Mucoepidermoid carcinoma

Odontogenic Cysts

Dentigerous cysts

Odontogenic keratocyst

Ameloblastoma

Leukoplakia

Persistent white lesion that cannot be defined as another condition

Erythroplakia

Persistent red lesion that cannot be defined as another condition

Leukoplakia Risk Factors

Tobacco use

Alcohol abuse

Betel nut

HPV

Leukoplakia

Severe dysplasia

Full thickness of epithelium

Nuclear pleomorphism

Increased nuclear to cytoplasmic ratio

Loss of polarity

Hyperchromasia

Atypical mitotic figures

Bullous rete pegs

4-6% malignancy rate

Erythroplakia

May have a white component to the red velvety patch

20% progress to invasive squamous cell carcinoma

Esophagus

Foregut derivative that extends from the epiglottis to the gastroesophageal junction just above the diaphragm

Epiglottis

Cartilaginous flap that prevents fluid, saliva, and foods from entering the trachea and lungs

Closes with swallowing and diverts these substances to the esophagus

Histology of Esophagus

Stratified squamous epithelium

Submucosal glanfs - secrete mucin and bicarbonate

Nerves - vagus (CN X)

Esophagus Muscle Layers

Upper 1/3 - skeletal

Middle 1/3 - mixed

Lower 1/3 - smooth

Peristalsis

Involuntary wave like muscle contractions propel content down esophagus

Atresia

Thin cord that replaces a segment of esophagus

Obstruction

Mechanical as in stenosis, which is the fibrous thickening & atrophy of muscle

Stenosis

Fibrous thickening and atrophy of muscle

Due to reflux, radiation tx, trauma, malignancy

Causes dysphagia

Esophageal Varices

Venous blood instead of returning directly to the heart from the Gi tract goes to the liver via the portal vein and then to vena cava

Diseases that impede portal vein flow cause portal hypertension which can cause this

Causes of Esophageal Varices

Cirrhosis of liver

Portal vein hypertension

Thrombus

Alcoholism

Varicose Veins

Abnormally dilated, tortuous veins

Caused by chronically increased intraluminal pressures and weekend wall support

Occurs at legs, esophagus, rectum, lips, and mouth

Varicose Veins Causes

Chronically increased intraluminal pressures and weakened wall suppot

Varicose Veins Problems

Lower extremity stasis

Congestion

Edema

Pain

Thrombosis

Ulcers

Sublingual Varices

Associated with

Lower limb extremities

Tobacco use

Family history

Type II diabetes

Hypertension

R heart failure

Congestive heart failure

Esophageal Varices Scopy

Bulging vessels - endoscopy

Dilated and congested veins - microscopy

Complication of Esophageal Varices

Hemorrhage - important cause of massive, life threatening bleeding

Esophagitis

Chemical and infectious resulting from the use of meds, which adhere to esophageal lining, dissolving it

Infectious is typically caused by HSV, CMV, fungal organisms and bacteria - cause necrosis of lining mucosa

Meds Causing Esophagitis

Doxycycline

Bisphosphonates

Infectious Esophagitis

Caused by HSV, CMV, fungal organisms and bacteria

Cause necrosis of lining mucosa

Mallory-Weiss Tears

Esophageal laceration

Superficial linear tears caused by severe retching of vomiting

Signs is hematemsis

Esophageal Perforation

Full thickness tear through muscular wall

Allows food, saliva, and digestive fluids into chest cavity

Mediastinitis

Severe infection of the central cavity of chest

Risk of esophageal perforation

Causes of Esophageal Perforation

Medical producedures

Severe vomiting

Weightlifting

Coughing

Ingested foreign objects

Corrosive chemicals

Traumatic injury

GERD

Malignancies

Symptoms of Esophageal Perforation

Severe chest and epigastric pain

Hematemesis

Subcutaneous emphysema

Dysphagia

Dyspnea

Septic shoc

Eating Disorder Soft Tissue Lesions

Palatal ecchymosis

Oral ulcers

Erosion of teeth

Coated tongue

Candidiasis

Oropharyngeal

Esophageal

Reflux Esophagitis

Caused by gastric contents coming back into the lower esophagus and represents the most common cause of this

Linked to GERD

Epithelium of the esophagus ulcerates causing symptoms

Gastroesophageal Reflux Disease (GERD)

Reflux of gastric contents is the most frequent cause of esophagitis

Esophageal lining is resistant to abrasion but sensitive to acid

Reflux of gastric fluids is central to development of mucosal injury

Physical Cause of GERD

Sphincter opening allowing for acid reflux

Microscopy of GERD

Erosions and ulcers

Elevated rete ridges

Basal cell hyperplasia

Intraepithelial eosinophils and neutrophils

GERD Associated Conditions

Obesity

Asthma

Pregnancy

Hiatal hernia

Diet

Smoking

Alcohol

Autoimmune disease

Delayed gastric emptying

Hiatal Hernia

Upper part of stomach bulges into chest through a small opening in diaphragm

Associated with GERD

Oral Complications of GERD

Halitosis

Tooth erosion

Oral erythema & ulcers

Coated tongue

Burning sensation

Sensitive mouth

Dysphagia

Lump in throat

Laryngitis

Lymphoid hyperplasia

Eosinophilic Esophagitis

Chronic immunologic disorder characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophilic inflammation

Most patients are atopic - atopic dermatitis, allergic rhinitis, and asthma

Symptoms of Eosinophilic Esophagitis

Food impaction and dysphagia in adults and GERD-like symptoms in children

Microscopy of Eosinophilic Esophagitis

Eosinophils

Micro-abscesses

Barrett Esophagus

Complication of chronic GERD

Metaplasia and dysplasia of the squamous epithelial lining of the esophagus

Epithelial dysplasia is a precursor for cancer

Barrett Esophagus Presentation

Red mucosal patch

Esophageal squamous mucosa & metaplastic mucosa containing goblet cells

Clinical Features of Barret Esophagus

GERD symptomatology and progressive weight loss

An endoscopy with biopsy is diagnostic

Esophageal dysplasia can transition to adenocarcinoma over time

Treatment - surgical including esophagostomy or mucosal stripping

Esophageal Tumors

Adenocarcinoma (glands) arising in a background of Baret esophagus and long standing GERD

Chromosomal anomlaies and TP53 mutations

Squamous cell carcinoma

Squamous Cell Carcinoma

Arising from excessive alcohol

tobacco

Frequent consumption of hot fluids

Esophageal injury

Plummer Vinson syndrome

Esophageal Adenocarcinoma

Back to back atypical glands

Mucin filled ducts

Esophageal Squamous Cell Carcinoma

Gross - white, wrinkled plaques

Tumor in the upper 1/3 of esophagus tend to spread to cervical lymph nodes

Stomach Disorders

Most result in clinical symptoms of gastritis - acute or chronic

Gastric lumen is low pH

Acute Gastritis Causes

NSAIDs

Gastric injury

Reduced mucin and bicarbonate secretion

Hypoxia at high altitudes

Ingestion of harsh chemicals, including alcohol

Chronic Gastritis

Most common cause is H. pylori

Another important cause is chronic NSAID use

Nausea

Upper abdominal discomfort with vomiting and bleeding

Autoimmune Gastritis

Most common cause when there is no H. pylori

Pernicious anemia

Pathogenesis of Chronic Gastritis

Hyperacidity

Gastric atrophy

Mucosal metaplasia

Increasing the risk for gastric adenocarcinoma

Caused by H. pylori

H. Pylori

Motile in the gastric mucosa because they have flagella

Can adhere to the epithelial surface and then secrete toxins that erode gastric mucosa

Chronic Gastritis Microscopy

H. pylori

Goblet cell and squamous cell metaplasia

Stomach lining

Detecting H. Pylori

Serologic test for antibodies and PCR for bacterial DNA

Treatment of Chronic Gastritis

Antibiotics and proton pump inhibitors

Can cause dysbiosis and malabsorption syndromes

Pernicious Anemia

Type of megaloblastic anemia

Results from poor absorption of Vitamin B12

• Autoimmune attack on gastric mucosa & suppress intrinsic factors, depleted reservoirs

Caused by gastrectomy, ileal resection, Crohns disease

Increased risk for gastric carcinoma

Vitamin B12

Needed for thymine synthesis

DNA replication

Signs of Pernicious Anemia

Neurologic symptoms

Fatigue, pallor, glossitis, numbness and tingling of extremities

Severe symptoms including dyspnea and congestive heart failure

Glossitis

Can be seen with iron deficiency and pernicious anemia

Peptic Ulcer Disease Signs

Pain - 1 to 3 hours after meals and is worse at night and relived by eating

Nausea

Bloating

Belching

Peptic Ulcer Disease Complications

Iron deficiency anemia

Hemorrhage

Perforation

Recurrent Aphthous Ulcers

Clinically may mimic a peptic ulcer but not associated with H. pylori

NSAIDs can cause this - drug induced allergic reaction

Polyps

Nodular mucosal masses that project above the level of the surrounding mucosa

Inflammatory, fundic, adenomas, some associated with syndromes

Adenomas

Dysplastic and those bigger than 2 cm are very high risk for adenocarcinoma

Gastric Polyps Mimic

Irritation fibroma

Pyogenic granuloma

Gastric Adenocarcinoma

Most common malignancy of stomach

Symptoms similar to gastritis and polyps

Weight loss, altered bowel habits, anemia, and hemorrhage

Risk Factors of Gastric Adenocarcinoma

Mucosal atrophy

Intestinal metaplasia

Sporadic Pathogenesis of Gastric Adenocarcinoma

Gene mutations

TP53

CHD1

HER2

Inherited Pathogenesis of Gastric Adenocarcinoma

APC gene which is a negative regulator of WNT pathway - associated with gastric and colorectal polyps

H. pylori

Epstein-Barr virus

Adenomatous Polyposis Coli (APC)

Negative regulator of WNT pathway

Associated with gastric and colorectal polyps

Gastric Adenocarcinoma Intestinal Microscopy

Neoplastic glandular structures

Gastric Adenocarcinoma Diffuse Microscopy

Classic cell is signet ring cell with large cytoplasmic vacuoles

Treatment of Gastric Adenocarcinoma

Surgical resection - limited impact of chemotherapy

Adenocarcinoma in Oral Cavity

Many benign and malignant types that arise from minor and major salivary glands

Mucoepidermoid carcinoma most common malignant type

Most commonly on palate and parotid gland

Lymphoma

Extra-nodal occur in the GI particularly in the stomach

B-cell cancer alled MALT - low grade

Gastric MALT Lymphoma

Associated with gastritis caused by H. pylori infection

Gastric mucosa most common site