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| {{Top | | <noinclude>{{Top |
| |author1=[[User:Mikael Häggström|Mikael Häggström]] | | |author1=[[User:Mikael Häggström|Mikael Häggström]] |
| |author2= | | |author2= |
| }} | | }} |
| | | {{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]]''' |
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| ===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.
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| 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.
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| File:Barrett's mucosa, high-grade dysplasia.jpg|'''High-grade dysplasia''': highly dysplastic cells
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| File:Histopathology of esophageal carcinoma.jpg|Esophageal '''adenocarcinoma'''
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| </gallery> | | </gallery> |
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| ===In absence of intestinalized mucosa===
| | {{further|Barrett's esophagus}} |
| [[File:Histopathology of acute and chronic inflammation of the gastro-esophageal junction, annotated.jpg|thumb|190px|GE junction with chronic '''esophagitis''', including plasma cells (black arrow), an acute inflammation with neutrophils (white arrow), as well as basal layer hyperplasia (yellow double-headed arrow).]]
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| 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|website=Pathology Outlines}} Topic Completed: 1 October 2012. Minor changes: 8 July 2020</ref>
| | {{Esophagitis}} |
| *'''Inflammatory cells''', especially when intra-epithelial. Neutrophils confer a diagnosis of acute inflammation, while plasma cells, eosinophils and excess T cells confer a diagnosis of chronic inflammation.
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| *'''Basal cell hyperplasia''' exceeding 15 - 20% of the epithelial thickness.
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| *'''Stromal papillae''' reaching upper third of the epithelium.
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| *'''Ballooned squamous cells'''
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| <gallery>
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| File:Histology of an eosinophil in esophageal epithelium.jpg|thumb|180px|An intra-epithelial eosinophil (characterized by its bilobed nucleus despite scant visible eosinophilic cytoplasm)
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| </gallery>
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| ===Report=== | | ===Report=== |
| {{Comprehensiveness|noheader=yes}} | | {{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}} |
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| Examples: | | Examples: |
| {|class=wikitable | | {|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's) mucosa.{{Moderate-end}} | | | {{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}}. |
| |} | | |} |
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| | In case of multiple signs of reflux esophagitis: |
| {|class=wikitable | | {|class=wikitable |
| | {{Moderate-begin}}GE junction, biopsy:{{Moderate-end}}<br>Squamous mucosa, '''negative''' for significant histopathologic changes.<br>{{Moderate-begin}}Negative for gastric mucosa or intestinalized (Barrett's) mucosa.{{Moderate-end}} | | | {{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> |