Gastroesophageal junction: Difference between revisions

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{{Endoscopic biopsies}}
{{Comprehensiveness}}</noinclude>
==Microscopic examination==
==Microscopic examination==
[[File:Histopathology of non-dysplastic Barret's esophagus.jpg|thumb|Histopathology of non-dysplastic Barret's esophagus (NDBE). Yellow arrow in a indicates goblet-cell-positive mucosa adjacent to the squamocolumnar junction.<ref>{{cite journal|last1=Riegler|first1=M.|last2=Kristo|first2=I.|last3=Nikolic|first3=M.|last4=Rieder|first4=E.|last5=Schoppmann|first5=S. F.|title=Update on the management of Barrett’s esophagus in Austria|journal=European Surgery|volume=49|issue=6|year=2017|pages=282–287|issn=1682-8631|doi=10.1007/s10353-017-0504-y}}<br>- Fig 2- available via license: Creative Commons Attribution 4.0 International</ref>]]
The main findings to look for are:
The main finding to look for is '''intestinalized mucosa''' (Barret's esophagus), which is defined as the presence of columnar epithelium with goblet cells.<ref>{{cite web|url=http://surgpathcriteria.stanford.edu/gi/barrett-esophagus/printable.html|title=Barrett Esophagus|website=Stanford University School of Medicine|accessdate=2020-09-01}}</ref> A true goblet cell should have rounded shape, clear to bluish cytoplasmic mucin, and be randomly scattered.<ref name=PathologyOutlines>{{cite web|url=http://www.pathologyoutlines.com/topic/esophagusBarrettsgeneral.html|title=Esophagus - Premalignant - Barrett esophagus|author=Dipti M. Karamchandani}} Topic Completed: 19 March 2020, Minor changes: 29 June 2020</ref> The mucin usually indents the nucleus.<ref name=PathologyOutlines/>
*'''[[Barrett's esophagus|Intestinalized mucosa]]''' ([[Barrett's esophagus]])
*(Reflux) '''esophagitis'''.
*'''Gastritis'''. {{Further|Stomach|linebreak=no}}
*'''[[Esophageal adenocarcinoma]]'''


===Further workup of intestinalized mucosa===
===Barrett's esophagus===
If intestinalized mucosa (Barret's esophagus) is present, look for dysplasia:
The main diagnostic sign of Barrett's esophagus is the presence of '''goblet cells'''. A true goblet cell should have rounded shape, clear to bluish cytoplasmic mucin, and be randomly scattered.<ref name=PathologyOutlines-Barrett>{{cite web|url=http://www.pathologyoutlines.com/topic/esophagusBarrettsgeneral.html|title=Esophagus - Premalignant - Barrett esophagus|author=Dipti M. Karamchandani}} Topic Completed: 19 March 2020, Minor changes: 29 June 2020</ref> The mucin usually indents the nucleus.<ref name=PathologyOutlines-Barrett/>
<gallery mode=packed heights=200>
<gallery mode=packed heights=220>
File:Barrett's mucosa, low-grade dysplasia.jpg|'''Low-grade dysplasia''': Simple straight but elongated tubules lined by dysplastic cells.
File:Histopathology of Barrett's esophagus, annotated.jpg|Histopathology of '''[[Barrett's esophagus]]''', showing intestinalized epithelium with goblet cells, as opposed to normal stratified squamous epithelium of the esophagus, and pseudostratified columnar epithelium of the fundus of the stomach. H&E stain.
File:Barrett's mucosa, low-grade dysplasia, low-power view, H&E.jpg|'''Low-grade dysplasia''': Elongated tubules crowded together.
File:Histopathology of goblet cells (annotated) and foveolar cells in incomplete Barrett's esophagus.jpg|In '''incomplete''' intestinal metaplasia, there are both foveolar cells and goblet cells, the latter (indicated by arrows) usually having a slightly bluish color compared to the apical cytoplasm of foveolar cells. An occasional but specific sign of goblet cells is crescent shaped nuclei (seen in middle one).
File:Barrett's mucosa, low-grade dysplasia, H&E.jpg|'''Low-grade dysplasia''': Crowded glandular profiles lined by atypical cuboidal cells. These contain basally oriented, enlarged vesicular nuclei and prominent nucleoli.
File:Barrett's mucosa, low-grade dysplasia, high-power magnification.jpg|'''Low-grade dysplasia''': Pseudostratified epithelium, with hyperchromatic elongated nuclei occupying much of the cells.
File:Barrett's mucosa, high-grade dysplasia, high-power magnification, H&E.jpg|'''High-grade dysplasia''': The cells are cuboidal and the nuclei have lost their normal basal polarity.
File:Barrett's mucosa, high-grade dysplasia.jpg|'''High-grade dysplasia''': highly dysplastic cells
File:Histopathology of esophageal carcinoma.jpg|Esophageal '''adenocarcinoma'''
</gallery>
</gallery>


===In absence of intestinalized mucosa===
{{further|Barrett's esophagus}}
Look for signs of (reflux) '''esophagitis''', mainly:<ref name=PathologyOutlinesEsophagitis>{{cite web|url=http://www.pathologyoutlines.com/topic/esophagusreflux.html|title=Esophagus - Esophagitis - Reflux esophagitis / gastroesophageal reflux disease|author=Elliot Weisenberg}} Topic Completed: 1 October 2012. Minor changes: 8 July 2020</ref>
 
*Inflammatory cells in the epithelial layer (mainly eosinophils, neutrophils, excess T cells).
{{Esophagitis}}
*Basal cell hyperplasia exceeding 15 - 20% of the epithelial thickness.


===Report===
===Report===
{{Moderate-begin}}Document the '''type of mucosa''':
*If both gastric and squamous mucosa is present in the same fragment, report as "'''Gastroesophageal junctional mucosa with...'''"
*If not, report the presence of '''squamous''' and/or '''gastric mucosa'''.{{Moderate-end}}
Examples:
Examples:
{|class=wikitable
{|class=wikitable
| Gastroesophageal junctional mucosa with chronic inflammation and reactive changes, non-specific.<br>Negative for intestinalized (Barrett's) mucosa.
| {{Moderate-begin}}GE junction, biopsy:{{Moderate-end}}<br>Squamous mucosa without significant histopathologic changes.<br>{{Moderate-begin}}Negative for gastric mucosa or intestinalized (Barrett-type) mucosa.{{Moderate-end}}<br>{{Comprehensive-begin}}Negative for dysplasia and malignancy.{{Comprehensive-end}}
|}
 
{|class=wikitable
| {{Moderate-begin}}GE junction, biopsy:{{Moderate-end}}<br>Gastroesophageal junctional mucosa with '''chronic inflammation''' and reactive changes{{Moderate-begin}}, non-specific.<br>Negative for intestinalized (Barrett-type) mucosa.{{Moderate-end}}{{Comprehensive-begin}}, dysplasia, and malignancy{{Comprehensive-end}}.
|}
|}


In case of multiple signs of reflux esophagitis:
{|class=wikitable
{|class=wikitable
| Squamous mucosa, negative for significant histopathologic changes.<br>Negative for gastric mucosa or intestinalized (Barrett's) mucosa.
| {{Moderate-begin}}GE junction, biopsy:{{Moderate-end}}<br>Gastroesophageal junctional mucosa with changes consistent with '''reflux esophagitis'''.<br>{{Moderate-begin}}Negative for intestinalized (Barrett-type) mucosa{{Moderate-end}}{{Comprehensive-begin}}, dysplasia, and malignancy{{Comprehensive-end}}.
|}
|}
{{Bottom}}
<noinclude>{{Bottom}}</noinclude>
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