病理學(xué)課件 消化系統(tǒng)1 2014.5

2ThedigestivesystemThegastrointestinaltractTheliverandthebiliarytractThepancreas3DiseasesoftheGITractEsophagusStomachSmallandlargeintestinesAppendixBarrettesophagusPepticulcerIBDEsophagealCaGastricCaColorectalCaAnatomic/Development/motorDisordersInflammatoryDiseases

Esophagitis

GastritisEnterocolitisAppendicitisTumorsAdenomaReflux~

Chronic~Carcinoid(NETs)4Normalanatomyandhistologyoftheesophagus5NormalanatomyandhistologyoftheesophagusEsophagogastricjunction≠Squamous-Columnarjunction6EsophagitisInflammationoftheesophagealmucosaCausedbyavarietyofagentsBiologicPhysicalChemicalRefluxofgastriccontentsisthemostimportantcauseofesophagitis(refluxesophagitis)7

Refluxesophagitis(返流性食管炎)ElongationofthelaminapropriapapillaeExtendingintothetopthirdoftheepitheliumBasalcellhyperplasia>1/5oftheepithelialthicknessIntraepithelialinflammatorycellsEosinophils,neutrophilsandlymphocytes

89Refluxesophagitis

ClinicalfeaturesAgeOver40yOccasionallyseenininfantsandchildrenDominantmanifestationHeartburn(燒心)Regurgitationofasourbrash(返酸)PotentialconsequencesBleeding,ulceration,strictureAtendencytodevelopBarrettesophagus10Barrettesophagus(巴雷特食管)DefinitionThereplacementofthenormaldistalstratifiedsquamousmucosabymetaplasticcolumnarepithelium,usuallycontaininggobletcellsAcomplicationoflong-standinggastroesophagealreflux11Diagnosticcriteria

EndoscopicevidenceofcolumnarepithelialliningabovethegastroesophagealjunctionHistologicevidenceofintestinalmetaplasiainthebiopsyspecimensfromthecolumnarepithelium.12BarrettesophaguswithdysplasiaThemostimportantriskfactorforesophagealadenocarcinoma1314CarcinomasoftheesophagusWorldwide,squamouscellcarcinomasconstitute90%ofesophagealcancersMainlyinnorthChinaandMiddleEastAsiaAccountfor20%ofcancerdeathsButinmostofthewesterncountries……AdenocarcinomaSCC15DietaryDeficiencyofvitamins(A,C,B1,B2,B6)Deficiencyoftraceelements(zinc,molybdenum鉬)FungalcontaminationoffoodstuffsHighcontentofnitrites(亞硝酸鹽)/nitrosamines(亞硝胺)FactorsAssociatedwiththeDevelopmentofSquamousCellCarcinomaoftheEsophagusLifestyleBurning-hotbeveragesorfoodAlcoholconsumptionTobaccouseEsophagealDisordersLong-standingesophagitisAchalasia(賁門失遲緩癥)Plummer-VinsonsyndromeGeneticPredispositionLong-standingceliacdisease(乳糜瀉)Ectodermaldysplasia(外胚層發(fā)育不良)RacialdispositionIntraepithelialneoplasm(上皮內(nèi)腫瘤)<1/2lowgrade>1/2highgrade(includeCainsitu)17CarcinogenesisofesophagealCaLowgradedysplasiaSquamousepitheliumEsophagitisSCCHyperplasiaMetaplasia(barrett)HighgradedysplasiaAdenoCaCarcinomainsitu18CarcinomasoftheesophagusClinicalfeaturesAge:middletoelderageGender:Male>Female(4-5:1)Insidiousinonset,dysphagia(吞咽困難),obstruction,progressiveweightloss,…RoutinescreeningproceduresarerequiredforpatientswithchronicesophagitisandBarrettesophagusLocationSCC:Upperthird20%Middlethird50%Lowerthird30%Adenocarcinoma:lowerthird19Macroscopicappearance2021Squamouscarcinoma22Adenocarcinoma23Adenocarcinoma24EarlyCaAcarcinomaconfinedtothemucosaormucosaandsubmucosaThefive-yearsurvivalrate:75%AdvancedCaThefive-yearsurvivalrate:10%-20%2526NormalanatomyandhistologyofthestomachLoweresophagealsphincter2728GastritisDefinition:InflammationofthegastricmucosaAcutegastritisFocaldamagetothegastricmucosa,withacuteinflammation,erosionandhemorrhage,usuallytransientClinicalmanifestation:rangefromentirelyasymptomatictofatalEtiology:drugs(aspirin),smoking,alcohol,severestress,infection,etc.29GastritisChronicgastritis

ThepresenceofchronicmucosalinflammatorychangesleadeventuallytomucosalatrophyandintestinalmetaplasiaEtiology

Helicobacterpylori(幽門螺桿菌)Autoimmune

GastroduodenalrefluxHotfoodsorbeveragesAlcoholMalnutrition30NoninvasiveNon-sporeformingSea-gullorS-shapedGramnegativeSliverstainMotilityElaborationofureaseExpressionofbacterialadhesinsExpressionofbacterialtoxins31MacroscopicappearanceUsuallyreddenedandcoarseSometimesthickenedWithlong-standingatrophicdisease,themucosamaybecomethinnedandflattenedChronicgastritis32Chronicgastritis

Chronicsuperficial/non-atrophicgastritis(慢性淺表性/非萎縮性胃炎)Inflammatoryinfiltrate:lymphocytesandplasmacellsinthelaminapropriaNoevidentofglandlossandmucosalatrophy

33TypeAAutoimmune-relatedPerniciousanemia(惡性貧血)APCA+IFA+Body/fundusDiffusedlesionTypeBH.PyloriassociatedNoanemiaAPCA-IFA–Antrum/pangastritisFocaldistributionChronicatrophicgastritis34InflammatoryinfiltrateAtrophyMetaplasiaIntestinal~(腸上皮化生)Pyloricgland~(幽門腺化生)DysplasiaMicroscopy35ClinicalfeaturesUpperabdominaldiscomfortNauseaandvomitingPerniciousanemia----autoimmunegastritisComplicationsPepticulcersCarcinomaLymphoma-MALToma3637Pepticulcer(消化性潰瘍)AbreachinthemucosaofthealimentarytractthatextendsthroughthemuscularismucosaintothesubmucosaordeeperMostcommonlyintheduodenumandstomachUlcervsErosionEpithelialdisruptionwithinthemucosabutnobreachofthemuscularismucosa38Pathogenesisofpepticulcers

39TherolesofH.pyloriinthepathogenesisofpepticulcers1Bacterialgeneproductscauseepithelialinjuryandinductionofinflammation2Enhancesgastricacidsecretionandimpairsduodenalbicarbonateproduction3Bacterialplatelet-activatingfactorpromotesthromboticocclusioninthesurfacecapillaries4Immunogenicproteinsevokerobustimmuneresponseinthemucosa40MorphologyofpepticulcersLocationsAnteriorandposteriorwallofthefirstportionoftheduodenumLessercurvatureofthestomachMacroscopicappearance2-4cmindiameterRoundtooval,sharplypunched-outNoelevatedmarginsSmoothandcleanbase41MicroscopyDefectsinthemucosapenetrateatleastintothesubmucosaNecroticfibrinoiddebrisNon-specificinflammatoryinfiltrate,predominatelyneutrophilsActivegranulationtissueinfiltratedwithmononuclearleukocytesFibroustissueorscar42ClinicalfeaturesSymptomsEpigastricgnawingBurningBoringpainComplicationsBleeding:15%-20%,1/4ofulcerdeathPerforation:5%,2/3ofulcerdeathObstruction:2%4344GastriccarcinomasEpidemiologyThesecondmostcommontumorintheworld,verycommoninChinaMale:Female=2:1AsteadydeclineinboththeincidenceandthemortalityoverthepastsixdecadesRiskfactorsH.pyloriinfectionDietBilerefluxGenetics45MorphologyofgastriccarcinomasLocationThelessercurvatureoftheantropyloricregionMacroscopicappearance4647UlcerativeCavsbenignulcerBordersRoundtoovalwithstraightwallsLeveledwiththesurroundingmucosa

Base:smoothandcleanGastricfolder:radiatingBordersIll-definedIrregular,heaped-upBase:shaggy,necroticGastricfolder:disappearorinterrupted48DiffusetypegastricAdenocarcinomaLinitisplastica(皮革胃)----"leatherbottle"appearance49HistologicclassificationofgastriccarcinomasTheWHOclassificationPapillaryadenocarcinomaTubularadenocarcinomaMucinousCaSignetringcellCaanditsvariantsAdenosquamousCaSquamousCaUndifferentiatedCaOthers505152LaurénclassificationIntestinaltype

BecomposedofglandularstructuresElderlypatientsThroughthesequenceofchronicgastririsIMDysCaH.pyloriassociatedDiffusetypeBecomposedof

poorlydifferentiateddyscohesivemalignantcellsYoungerpatientsEtiologyandprecancerouslesionsunknown53ClinicalfeaturesWeightlossAnorexia,dyspepsia,earlysatietyAnemia(irondeficiency),hematemesisLeftsupraclavicular(鎖骨上)lymphnode(Virchownode,

魏爾嘯淋巴結(jié))enlargementKrukenbergtumor:intraperitonealspreadtobothovariesPrognosis:largelydependsonthedepthofinvasionandthecondition