. 4
( 10)


4-7. Sclerosing cholangitis in a patient with ulcer-
ative colitis. Note the marked hepatic ¬brosis that
has occurred secondary to ¬brous obliteration of
many of the intra- and extrahepatic bile ducts.
Cholestasis is a prominent feature.

212 Liver, Biliary System, and Pancreas


4-8. Precirrhotic alcoholic liver disease. A. Extremely
fatty liver (steatosis) in a chronic alcoholic. B. Micro-
scopically, the hepatocytes look more like adipocytes.
C. Intracellular deposits of Mallory™s alcoholic hya-
line are indicated by arrows.

Liver, Biliary System, and Pancreas 213


4-9. Micronodular cirrhosis of the liver. A. Note the
uniformly ¬ne, nodular upper surface of the liver.
B. Cut surface of ¬xed liver shows regenerating nod-
ules that are less than 3 mm in diameter. Some nod-
ules are bile stained due to the nodules failing to
attain an adequate connection to the biliary
drainage system.

214 Liver, Biliary System, and Pancreas

4-10. A. Mixed micro- and macronodular cirrhosis of
the liver in a patient with hepatis virus C infection.
A transvenous intrahepatic portosystemic shunt
(arrow) is present in the transected portal vein at the
porta hepatis. B. Histology shows cirrhosis with evi-
dence of persistent chronic hepatitis (numerous lym-
phocytes are present in the portal tracts).


Liver, Biliary System, and Pancreas 215
4-11. Patient with hemochromatosis (bronzed dia-
betes). A. Hemochromatosis-induced micronodular
cirrhosis due to defective intestinal mucosal block
for iron absorption. The liver has a distinctly brown
color due to excessive deposition of hemosiderin
within the hepatocytes. B. Perl™s Prussian blue stain
shows excessive intrahepatic iron deposits.


216 Liver, Biliary System, and Pancreas


4-12. Patient with an alpha-1-antitrypsin de¬-
ciency. A. Micronodular cirrhosis of the liver with
two larger nodules (arrows) of early, multicentric
hepatocellular carcinoma. B. Immunoperoxidase
staining reveals excessive accumulation of alpha-1-
antitrypsin within hepatocytes due to dif¬culty
with its exosecretion from these cells.

Liver, Biliary System, and Pancreas 217
4-13. Micronodular cirrhosis in a patient with pro-

4-14. Mixed micro- and macronodular cirrhosis in
a patient with tyrosinemia.

4-15. Close-up view of inferior hepatic surface showing mixed
micro- and macronodular cirrhosis. Micronodular cirrhosis tends
in time to become converted into a macronodular form. Macron-
odular cirrhosis may also follow submassive necrosis of the liver.

218 Liver, Biliary System, and Pancreas

4-16. A. Submassive necrosis of the liver is evolv-
ing into macronodular cirrhosis. B. Histology of
postnecrotic regeneration of the liver 16 days after
submassive necrosis. Some of the regenerating
hepatocytes appear enlarged and atypical.


Liver, Biliary System, and Pancreas 219


4-17. A and B. Macronodular cirrhosis of the liver
in two patients with hepatitis B virus infection.
C. Positive immunoperoxidase staining for hepatitis
B core antigen in the liver.

220 Liver, Biliary System, and Pancreas
4-18. Macronodular cirrhosis complicated by a hepatocellular
carcinoma in a patient with chronic hepatitis B infection. A
bisected transvenous intravascular portosystemic shunt is
observed in the lower liver slice.


4-19. A. Portal vein thrombosis complicating micron-
odular cirrhosis. B. Histology shows an early organ-
izing thrombus within the portal vein. A totally
recanalized thrombus is referred to as cavernous
transformation of the portal vein.


Liver, Biliary System, and Pancreas 221

4-20. A. Biliary cirrhosis due to long-standing
obstruction to biliary ¬‚ow. B. Cirrhosis and marked
obstruction to bile ¬‚ow is noted histologically.


222 Liver, Biliary System, and Pancreas

4-21. A. Congenital extrahepatic biliary atresia has
led to incipient cirrhosis of the liver in an infant.
B. Histology shows ¬brosis linking portal tracts and
marked centrilobular cholestasis.


Liver, Biliary System, and Pancreas 223
4-22. Hepar lobatum of the liver. Healing of multi-
ple gummata of tertiary syphilis has produced
pseudolobulation of the liver due to in-drawing of
the capsule by the ¬brous scars.

4-23. A. Nutmeg liver of chronic passive conges-
tion. B. Histology shows that marked centrilobular
congestion has led to centrilobular zonal necrosis.


224 Liver, Biliary System, and Pancreas
4-24. A. Cardiac “cirrhosis” of the liver comprises
hepatic ¬brosis and signs of regenerative activity
secondary to long-standing, right-sided cardiac fail-
ure. B. Histology shows hepatic ¬brosis without fea-
tures of true cirrhosis.


Liver, Biliary System, and Pancreas 225
4-25. A. Focal areas of increased congestion of the
liver, plus parenchymal atrophy due to localized
venous obstruction, are termed Zahn infarcts. B. His-
tology shows intense congestion of the hepatic sinu-
soids, as well as tissue atrophy with some disruption
of the hepatic plates in areas secondary to the venous


226 Liver, Biliary System, and Pancreas


4-26. A. Recent massive ischemic infarction (pale
zones) of large areas of the liver in a young child who
suffered severe hypotension while undergoing cardiac
surgery. B. Well-established, pale areas of infarction of
the liver in an adult. C. Histology of recent ischemic
necrosis of the liver showing minimal periportal sur-
vival of hepatic parenchyma. The dilated sinusoids
give a spurious appearance of hemorrhage.

Liver, Biliary System, and Pancreas 227
4-27. A cirrhotic patient with bleeding from an
intrahepatic branch of the portal vein had this
intravascular coil inserted by a radiologist to try
and stop the bleeding. The thrombotic material
attached to the coil is intentional and furthers the
therapeutic occlusion of the vessel.

4-28. Nodular regenerative hyperplasia of the liver.
Note the multiple indistinct, pale-colored nodules.
Such patients may develop portal hypertension in
the absence of cirrhosis.

228 Liver, Biliary System, and Pancreas

4-29. A. Large yellow-white hepatocellular carci-
noma shows focal areas of hemorrhage and necro-
sis on its cut surface that bulges above the adjacent
compressed liver tissue. Note the absence of cirrho-
sis in the latter. B. Histology of moderately differ-
entiated hepatocellular carcinoma (top right) shows
the malignant cells to resemble normal liver cells
(lower left) in appearance, but they are larger in size
and more atypical looking.


Liver, Biliary System, and Pancreas 229
4-30. Hepatocellular carcinoma has invaded into
and is growing within the portal vein (circled).

230 Liver, Biliary System, and Pancreas

4-31. A. Bisected ¬brolamellar carcinoma of the
liver shows central degeneration and scarring. This
tumor occurs in younger patients without cirrhosis
and has a fairly good prognosis (50% cure rate). B.
The histology of the ¬brolameller carcinoma shows
small groups of malignant oncocytic-looking hepa-
tocytes surrounded by bands of ¬brous tissue.


Liver, Biliary System, and Pancreas 231

4-32. A. Cholangiocarcinoma (Klatskin tumor) is
invading into the proximal portion of the hepatic
duct in the porta hepatis. B. Histology shows a
poorly differentiated adenocarcinoma within per-
ineural lymphatics.


232 Liver, Biliary System, and Pancreas

4-33. A. Hepatoblastoma of the liver presenting as
a ¬‚eshy, focally hemorrhagic and necrotic solid
tumor. B. Histologically, the tumor shows a bipha-
sic pattern comprised of epithelial and mixed mes-
enchymal elements. Unlike a hepatocellular carci-
noma, the epithelial cells of a hepatoblastoma are
smaller than normal liver cells.


Liver, Biliary System, and Pancreas 233

4-34. A. Metastatic lymphoma presenting as multiple
variable-size white nodules in the liver. B. Histology
shows a diffuse anaplastic large cell lymphoma.


234 Liver, Biliary System, and Pancreas

4-35. Hemangioma of the liver may show a range of
appearances. A. Subcapsular (top right) cavernous
hemangioma of liver. B. Cavernous hemangioma is
characterized histologically by endothelial-lined
vascular spaces that are much wider in diameter
than capillaries. (continued on next page)


Liver, Biliary System, and Pancreas 235

4-35. (Continued) C. Partially thrombosed cav-
ernous hemangioma shows pale areas of organizing
thrombus within the hemangioma. D. Old throm-
bosed, organized, and partially calci¬ed cavernous
hemangioma of the liver.

236 Liver, Biliary System, and Pancreas

4-36. A. Multiple bile duct hamartomas (von
Meyenburg complexes) presenting as numerous
small, focal white nodules with some associated
¬brous tissue. The liver also has an overall nutmeg
pattern due to passive congestion. B. Histologically,
the hamartoma comprises a localized collection of
bile ductules in a loose connective tissue stroma. In
a patient undergoing laparotomy for intraabdominal
malignancy, the hamartomas may be biopsied for
frozen section to exclude metastatic carcinoma. Pol-
yarteritis nodosa may also lead to the formation of
von Meyenburg complexes via liver ischemia, but
the more usual effect on the liver is the production
of multiple saccular aneurysms along the course of
small arteries (see Fig. 4-70).


Liver, Biliary System, and Pancreas 237


4-37. A. Focal nodular hyperplasia of the liver
showing central degeneration and ¬brosis. B. The
central scarred zone is clearly evident on
microscopy of the lesion. C. The hyperplastic liver
cells (top) merge smoothly with the adjacent com-
pressed normal liver cells.

238 Liver, Biliary System, and Pancreas

4-38. The liver is a common site for metastatic
tumors. A. Multiple rounded nodules of metastatic
adenocarcinoma occupy much of the liver. B. His-
tology shows moderately differentiated adenocarci-
noma. (continued on next page)


Liver, Biliary System, and Pancreas 239


4-38. (Continued) C. Metastatic malignant melanoma
showing prominent melanin production in only some
of the nodules. D. Central umbilication due to central
necrosis of the tumor nodules is a common feature in
secondary cancers. (continued on next page)

240 Liver, Biliary System, and Pancreas

4-38. (Continued) E. Metastatic carcinoid tumor in
the liver that had produced the carcinoid syndrome
because the serotonin was able to bypass the liver™s
metabolism and gain entry into the systemic circu-
lation. F. Histology of carcinoid tumor showing
islands of uniform-looking cells devoid of anaplasia.


Liver, Biliary System, and Pancreas 241
4-39. Isolated simple cyst of the liver.

242 Liver, Biliary System, and Pancreas


4-40. A. Polycystic liver disease in an adult with
autosomal dominant (type III) polycystic kidney
disease. B. Transversely sectioned liver shows mul-
tiple, interconnecting cysts of varying size, more
abundant in the left lobe. C. Histologic appearance
of portion of a small cyst.


Liver, Biliary System, and Pancreas 243


4-41. Miscellaneous cysts of the liver. A. Hydatid
cyst of the liver whose contents have been evacu-
ated. Note that during aspiration or excision the
spillage of even a small amount of the cyst ¬‚uid
may induce anaphylaxis due to hypersensitivity to
the hydatid. B. Histology of the cyst wall showing
the presence of multiple diagnostic scolices lying
close to the detached germinal membrane. C. Muci-
nous cystadenoma of the ovary: the mucinous con-
tents lie to the right of the cyst.

244 Liver, Biliary System, and Pancreas

4-42. Amyloidosis of the liver. A. Macroscopically
the liver has a waxy, ¬rm, sharp-edged appearance,
and its weight is greatly increased. B. Microscopic
appearance of amyloid as eosinophilic, structure-
less, hyaline material replacing atrophic hepatic


Liver, Biliary System, and Pancreas 245

4-43. Peliosis hepatis. A. Bleeding derived from the
blood-¬lled spaces (peliosis hepatis), seen as darker
areas in the liver, has produced a large subcapsular
hematoma (top left). B. The histologic hallmark of
peliosis hepatis is disruption of the endothelial lin-
ing of the sinusoids with extravasation of blood out
of the sinusoids into Disse™s space and beyond to
produce blood-¬lled spaces within the liver.


246 Liver, Biliary System, and Pancreas

4-44. Hepatic venooclusive disease (HVOD).
A. Intense passive congestion of the liver due to
widespread severe obstruction to venous out¬‚ow
has produced a “super-nutmeg” pattern in the liver.
B. Elastic van Gieson stain shows signi¬cant nar-
rowing of a small sublobular hepatic vein due to


Liver, Biliary System, and Pancreas 247


4-45. Liver transplantation. A. Severe acute rejec-
tion has produced extensive necrosis of this donor
liver. B. Chronic rejection (graft arteriopathy) has
produced thickening of blood vessel walls, as well
as some atrophy and ¬brosis of the graft. (continued
on next page)

248 Liver, Biliary System, and Pancreas

4-45. (Continued) C. Jaundiced liver due to graft-
versus-host disease (GVHD) in a bone marrow trans-
plant recipient. D. Apoptotic destruction of bile
ductular epithelium due to GVHD.


Liver, Biliary System, and Pancreas 249
4-46. Intrahepatic pure pigment gallstones within
the dilated biliary tree. Partial hepatectomy was
performed after repeated attacks of cholangitis.

4-47. Gallstones lie within a dilated common bile

250 Liver, Biliary System, and Pancreas
4-48. Congenital choledochal cyst of the common
bile duct. Such cysts may occur inside or outside
the liver and may predispose to cholangitis. The
cysts are more common in Japan and affect girls
more than boys.

4-49. Strawberry gallbladder: cholesterosis gives the
mucosa a speckled appearance due to cholesterol-
laden macrophages in the lamina propria of the gall-

Liver, Biliary System, and Pancreas 251


4-50. A. Cholesterol-rich gallstones within a very
thickened, ¬brosed gallbladder. B. Bisected choles-
terol-rich gallstones within gallbladder show the
typical radiating crystalline appearance of choles-
terol crystals. (continued on next page)

252 Liver, Biliary System, and Pancreas

4-50. (Continued) C. Mixed cholesterol and bile pig-
ment stones. D. Chronic cholecystitis. Fibrosed gall-
bladder contains numerous multifaceted mixed

Liver, Biliary System, and Pancreas 253


4-51. A. Chronic cholecystitis has produced signif-
icant mural thickening of the gallbladder. B. Roki-
tansky-Aschoff sinuses (adenomyosis) in chronic
cholecystitis. C. Fibrous contracture of the gallblad-
der due to chronic cholecystitis related to calculi.
(continued on next page)

254 Liver, Biliary System, and Pancreas
4-51. (Continued) D. Histology shows ¬brous tissue
has replaced mucosa and the muscle coat. E. Muco-
cele of the gallbladder due to sterile obstruction of
the neck (see gallstone). The lack of in¬‚ammation
allows the gallbladder to distend with mucus with-
out rupturing. Such a gallbladder has to be carefully
handled during surgical excision to avoid rupture
and the implantation of mucus-secreting cells on
the peritoneum that may produce pseudomyxoma


Liver, Biliary System, and Pancreas 255
4-52. Granulomatous in¬‚ammation due to Trichos-
poron beigelii protruding externally from the wall
of the gallbladder.

4-53. Carcinoma of the gallbladder. A. Adenocarci-
noma (white tissue, bottom right) of a gallbladder
that contains a large gallstone. B. Diffusely in¬ltrat-
ing adenocarcinoma in a gallbladder containing
four gallstones.


256 Liver, Biliary System, and Pancreas

4-54. Necrosis of the gallbladder. A. Gangrene of
the gallbladder complicating acute cholecystitis.
B. Histologic appearance of ischemic cholecystopa-
thy shows fresh hemorrhage within the necrotic


Liver, Biliary System, and Pancreas 257
4-55. Surgical catheter drainage of the gallbladder
(bottom left) to remove sludge that had led to acute
hemorrhagic pancreatitis (top right) by obstructing
the ampulla of Vater.

4-56. Adenocarcinoma (arrow) of the ampullary
end of the common bile duct.

258 Liver, Biliary System, and Pancreas

4-57. Acute pancreatitis. A. Close-up view of cut sur-
face of hemorrhagic pancreatitis. B. Histology shows
necrotic pancreatic tissue (top left) surrounded by
hemorrhage and acute in¬‚ammation.


Liver, Biliary System, and Pancreas 259
4-58. Pancreatic pseudocyst (top left) in a patient with
recurrent acute hemorrhagic pancreatitis (center).

260 Liver, Biliary System, and Pancreas

4-59. Chronic calcifying pancreatitis. A. Pancreas
shows dense ¬brosis and calculi (arrows) within the
dilated pancreatic duct. B. More advanced chronic
calci¬c pancreatitis with both parenchymal and
intraductal calci¬c deposits. C. Histology shows
atrophic acini embedded in dense ¬brous tissue.


Liver, Biliary System, and Pancreas 261
4-60. Bisected pancreas showing calculus (arrows)
within pancreatic duct.

262 Liver, Biliary System, and Pancreas

4-61. Fat necrosis of the pancreas. A. Necrotic
interstitial ¬broadipose tissue of the pancreas has a
chalky yellow-white color due to the deposition of
triglycerides/fatty acids as calcium soaps. B. Histol-
ogy of fat necrosis showing central necrotic
adipocytes covered by fatty acids precipitated as
calcium soaps.


Liver, Biliary System, and Pancreas 263

4-62. Pancreas in cystic ¬brosis. A. Total adipose
replacement of the pancreatic parenchyma is more
commonly observed than the pancreatic cysts and
¬brosis after which the condition was originally
named. B. Histology shows naked islets of Langer-
hans (devoid of surrounding acinar tissue) lie
within the ¬broadipose tissue. C. Histology of
another pancreas showing cystic dilatation of ducts
and replacement ¬brosis of the parenchyma (i.e.,
cystic ¬brosis).



264 Liver, Biliary System, and Pancreas
4-63. Hemorrhagic infarction of the pancreas follow-
ing thrombotic obstruction of its venous drainage.

4-64. Pancreas in hemochromatosis (lower) shows
atrophy and brown coloration due to excessive
parenchymal iron deposits. Compare with a normal
control pancreas (upper) from another patient.

Liver, Biliary System, and Pancreas 265
4-65. Intraductal papillary mucinous neoplasm
(also termed pancreatic intraepithelial neoplasia)
may present varied gross features. In this patient,
multiple pancreatic ducts are dilated due to over-
production of mucus.

266 Liver, Biliary System, and Pancreas


4-66. A. Mucinous cystadenoma of tail of pancreas.
The unilocular cyst contains abundant inspissated
mucin. B. The lining comprises a single layer of
well-differentiated mucinous epithelium. Fibrosis is
noted in the adjacent compressed pancreatic tissue.
C. Mucinous cystadenocarcinoma of the tail of the
pancreas abuts on the spleen (left).

Liver, Biliary System, and Pancreas 267



4-67. Adenocarcinoma of the head of the pancreas.
A. Bisected carcinoma surrounds the common bile
(*) duct as it reaches the ampulla of Vater in the
second part of the duodenum. B. Cancer of the pan-
creas is beginning to invade into duodenum (left)
and extends to reach the inked resection line (right)
in this Whipple resection. C. Histology of a poorly
differentiated adenocarcinoma of the pancreas.

268 Liver, Biliary System, and Pancreas

4-68. A. Malignant lymphoma within the intra- and
peripancreatic lymph nodes is spreading into the
pancreatic parenchyma in areas. B. Histology shows
a diffuse, large cell lymphoma.


4-69. Ruptured mycotic aneurysm (arrow) of the
splenic artery in the head of pancreas.

Liver, Biliary System, and Pancreas 269


4-70. Polyarteritis nodosa of pancreas. A. Multiple
large thrombus-¬lled aneurysms within head of
pancreas. B. Multiple small aneurysms along the
course of a small intrapancreatic artery. C. Histol-
ogy shows a polymorphous in¬‚ammatory response
(including many eosinophils) in the wall of an
artery (top) and thrombus ¬lling a false aneurysm
that communicates with a small artery (bottom).


270 Liver, Biliary System, and Pancreas
4-71. Transplantation of the pancreas. A. Autopsy
revealed the donor pancreas to contain two small
accessory spleens (splenunculi) in its tail (top left).
The patient died of severe graft-versus-host disease
that may have been facilitated by the donor lym-
phoid containing splenic tissue present in the
donor pancreas. B. Chronic rejection of the pancreas
(graft arteriopathy) manifesting as thickened, nar-
rowed blood vessels and atrophic, ¬brosed

Liver, Biliary System, and Pancreas 271
5 Salivary Glands and GIT

5-1. Calci¬c calculus obstructs main duct of sub-
mandibular gland close to one end of the gland. The
parenchyma shows mild atrophy and ¬brosis.

272 Salivary Glands and GIT


5-2. A. Small circumscribed pleomorphic adenoma
of the parotid gland has a multilobulated variegated
cut surface. B. This pleomorphic adenoma has a
less well-de¬ned edge with isolated nodules of
tumor extending into the surrounding parenchyma
(top left). Incomplete excision of the tumor may
leave such nodules behind, leading to recurrence of
the tumor. Chondroid areas macroscopically appear
more mucoid. (continued on next page)

Salivary Glands and GIT 273

5-2. (Continued) C. Histology of pleomorphic ade-
noma (mixed parotid tumor), showing a mixture of
proliferating ductal and myoepithelial cells and
areas of myxoid and chondroid differentiation.
D. Cross-section of a pleomorphic adenoma that
was excised with minimal surrounding tissue. The
areas of myxoid/chondroid differentiation are eas-
ily apparent. E. Further excision revealed histologic
evidence of a residual nodule of tumor tissue that
abuts on the inked resection margin.


274 Salivary Glands and GIT
5-3. Malignant change in a pleomorphic adenoma
has converted the tumor into an adenocarcinoma
that has ill-de¬ned margins due to in¬ltration of the
adjacent salivary glandular tissue by the malig-

Salivary Glands and GIT 275

5-4. Monomorphic adenomas of the salivary glands
may occur (e.g., the most common are the Warthin
tumor [papillary cystadenoma lymphomatosum],
basal cell adenoma, oxyphilic adenoma [oncocy-
toma], canalicular adenoma, myoepithelioma, and
clear cell adenoma). Warthin tumors are more com-
mon in men and may be bilateral or multifocal in
the same gland. A. Early Warthin tumor (arrows)
has a lighter tan color than the normal glandular tis-
sue. B. This more advanced Warthin tumor shows
the more typical multicystic areas on its cut surface.
C. Histology: oncocytes line the ducts, some of
which have become expanded into cystic spaces.
Follicular lymphoid tissue is also present.


276 Salivary Glands and GIT


5-5. Malignant tumors of salivary glands include
mucoepidermoid carcinoma, adenoid cystic carci-
noma (cylindroma), and acinic cell carcinoma. A.
Acinic cell carcinoma of the parotid gland shows
areas of hemorrhage and necrosis on its cut surface.
B. Histology of acinic cell carcinoma shows cells
resembling the secretory (acinic) cells of normal
salivary tissue. Although the 5-year survival of
acinic cell carcinoma is very good, the 20-year sur-
vival is only about 50% due to a tendency for recur-
rences. C. Oncocytoma of the parotid gland.

Salivary Glands and GIT 277

5-6. A. Basaloid squamous carcinoma of the parotid
gland is invading the parenchyma and has spread
into the intraparotid lymph nodes. B. Histology of
basaloid squamous carcinoma shows focal squamous
differentiation in the islands of basaloid-looking cells.


5-7. Follicular lymphoma has replaced an intra-
parotid lymph node (arrows).

278 Salivary Glands and GIT

5-8. A. Herpetic ulceration of the tongue tip (left)
and lateral border (center). B. Numerous her-
pesvirus hominis intranuclear viral inclusions
within squamous epithelial cells at the edge of a
herpetic ulcer.


Salivary Glands and GIT 279

5-9. A. Squamous carcinoma of the lateral border of
the tongue has destroyed the surface integrity of the
tongue (center). B. Histology shows a well-differen-
tiated (keratinizing) squamous carcinoma.

280 Salivary Glands and GIT
5-10. Polypoid juvenile angio¬broma of the
nasopharynx in a teenage boy. Although a benign
tumor, it may be locally aggressive (e.g., it may
invade the skull bones). Biopsy is contraindicated
due to the highly vascular nature of the tumor. Radi-
ation treatment may be used in place of surgery.

5-11. Mucosal hemorrhage in the longitudinally
divided upper esophagus due to trauma by a mis-
directed endotracheal tube that was intended for
the trachea.

Salivary Glands and GIT 281
5-12. Squamous carcinoma of the proximal esoph-
agus presenting as both ulceration and thickening
of the inner lining of the esophagus.

5-13. Zenker (pulsion) diverticulum surgically
excised from the proximal esophagus. The patient
had suffered from regurgitation of food eaten days
prior, plus episodes of aspiration pneumonia. (In
contrast, a traction diverticulum occurs lower down
in the esophagus due to adherent tuberculous
lymph nodes. An epiphrenic diverticulum occurs
near the diaphragm in patients with re¬‚ux,
esophageal spasm, or achalasia.)

282 Salivary Glands and GIT

5-14. A. Focal, raised white plaques on the esophageal
mucosal lining due to glycogenic acanthosis. B. The
lesions comprise localized zones of squamous
epithelial cells containing abundant glycogen (vac-
uolated cytoplasm).


Salivary Glands and GIT 283
5-15. Linear ulceration (arrows) of the esophageal
mucosa secondary to pressure by a nasogastric tube.

284 Salivary Glands and GIT
5-16. A. Esophageal varices (arrow) have been ren-
dered prominent by turning the esophagus inside
out and ligating both ends to prevent the blood
draining out. B. Histologic appearance of a dilated
esophageal vein (varix) within the lamina propria
of the esophagus.


Salivary Glands and GIT 285
5-17. A. Herpetic ulceration of lower esophagus and
stomach. The ulcers are covered by a mixture of
necrotic epithelium, ¬brin, and some blood.
B. Herpetic (Cowdry type A) inclusions within squa-
mous epithelial cells bordering an esophageal ulcer.


286 Salivary Glands and GIT

5-18. A. Severe Candida esophagitis showing white
plaques and easily detachable pseudomembranes
resembling oral thrush on the mucosal surface of
the esophagus. B. Silver stain shows pseudohyphae
of pathogenic Candida, plus budding yeast forms of
the organism within the pseudomembrane.

Salivary Glands and GIT 287
5-19. The proximal portion of the esophagus has
been opened longitudinally to reveal a mucosal
plaque of infection by Aspergillus fungus that has


. 4
( 10)