Oesophageal Pathology
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Direct answer
Barrett oesophagus is the intestinal (columnar) metaplasia of the distal oesophagus that chronic acid reflux induces, identifiable as salmon-pink tongues above the gastro-oesophageal junction, carrying a risk of dysplasia and adenocarcinoma that mandates endoscopic surveillance. Achalasia cardia is failure of lower oesophageal sphincter relaxation from degeneration of myenteric ganglion cells, giving equal dysphagia to solids and liquids with regurgitation and a bird-beak on barium. Squamous cell carcinoma remains the commonest oesophageal cancer worldwide, linked to smoking, alcohol, very hot beverages and the Plummer-Vinson syndrome, while adenocarcinoma — rising in Western populations — grows on the soil of Barrett metaplasia and obesity.
What you must remember
- Reflux disease: acid-peptic injury of the squamous lining; complications are ulceration, peptic stricture and Barrett metaplasia — the sequence to quote when asked where adenocarcinoma comes from.
- Barrett oesophagus: intestinal metaplasia with goblet cells confirmed on biopsy; dysplasia graded low to high, with high-grade dysplasia managed by endoscopic resection or ablation rather than waiting for cancer.
- Achalasia: loss of myenteric (Auerbach) plexus ganglion cells — idiopathic, or infectious as in Chagas disease of South America; manometry is the diagnostic standard; barium shows a dilated oesophagus tapering to a bird-beak; longstanding achalasia raises squamous carcinoma risk.
- Varices: left gastric vein collaterals under portal hypertension; the source of major upper gastrointestinal bleeding in cirrhotics; distinguish from Mallory-Weiss tears — longitudinal mucosal lacerations at the junction after retching, which usually stop bleeding spontaneously — and from Boerhaave perforation, a full-thickness rupture with mediastinitis.
- Infective oesophagitis: Candida with white adherent plaques, herpes simplex with small discrete ulcers (Cowdry A inclusions), cytomegalovirus with larger linear ulcers (owl-eye inclusions) — the triad to know in immunosuppression.
- Squamous carcinoma risks: tobacco, alcohol, achalasia, caustic stricture, Plummer-Vinson syndrome (iron deficiency, upper oesophageal web, post-cricoid carcinoma in middle-aged women) and consumption of very hot beverages — the last formally classified as probably carcinogenic.
- Adenocarcinoma: Barrett-associated, obesity-linked, rising in the West; distal oesophagus and junction.
- The barium pair: achalasia gives a bird-beak; an annular carcinoma gives a rat-tail or shouldered irregular narrowing — reversed answers are a classic multiple-choice trap.
Three patterns of dysphagia at the bedside
Dysphagia sorts itself by tempo and symmetry. A 58-year-old with progressive difficulty, first solids then over months liquids, weight loss and anaemia has an obstructing carcinoma until endoscopy proves otherwise — the barium may show the irregular rat-tail before the scope reaches it, and biopsies confirm squamous or adenocarcinoma. A 35-year-old with years of equal dysphagia to solids and liquids, chest fullness after meals, regurgitation of undigested food at night and slow weight loss fits achalasia — the failure is motor, not mechanical, so the calibre of nothing is too small and the bird-beak is the sphincter that will not open; manometry shows absent peristalsis with incomplete relaxation, and high-resolution manometry now subtypes it into three types with different treatment responses.
The third pattern is episodic: food sticking abruptly then passing, often with heartburn history — peptic stricture or ring, benign and dilatable. Two clinical anchor syndromes complete the set: the cirrhotic who vomits blood has varices as the first assumption until scoped; and the middle-aged woman with fatigue, spoon-shaped nails and a web — Plummer-Vinson (Paterson-Brown Kelly) syndrome — whose upper oesophageal web is both the dysphagia cause and the marker of a mucosa primed for post-cricoid squamous carcinoma, which is why iron repletion and surveillance matter.
Where students slip
The bird-beak and rat-tail are memorised and then interchanged under exam pressure — anchor them by physics: a sphincter that cannot relax produces a smooth conical taper (bird-beak), a tumour produces an irregular shouldered cutoff (rat-tail). Second, Barrett is described as "gastric metaplasia"; the metaplasia is intestinal, with goblet cells, and that word carries the mark. Third, the infective oesophagitides are bundled into "candida in immunosuppression," but each virus keeps its ulcer habit — herpetic small and discrete, cytomegaloviral large and linear — a distinction that changes antiviral choice.
Frequently asked questions
What defines Barrett oesophagus histologically?
Intestinal-type columnar metaplasia with goblet cells in the distal oesophagus, caused by chronic reflux; surveillance detects dysplasia before adenocarcinoma.
Which investigation is the standard for achalasia and what does it show?
High-resolution manometry — absent peristalsis with incomplete lower oesophageal sphincter relaxation; barium shows the bird-beak taper.
What is the difference between Mallory-Weiss tear and Boerhaave syndrome?
Mallory-Weiss is a partial-thickness mucosal tear after retching that usually settles; Boerhaave is full-thickness rupture causing mediastinitis and surgical emergency.
Which viruses cause oesophageal ulcers in immunosuppression?
Herpes simplex (small discrete ulcers with Cowdry A inclusions) and cytomegalovirus (large linear ulcers with owl-eye inclusions); Candida gives white plaques.
What is Plummer-Vinson syndrome?
Iron deficiency anaemia with an upper oesophageal web and dysphagia, predisposing to post-cricoid squamous carcinoma in middle-aged women.
Which oesophageal cancer is associated with very hot beverages?
Squamous cell carcinoma — very hot drinks are classified as probably carcinogenic, a habit-relevant point in Indian tea consumption.