Esophagus

Front 1

Esophageal pain → medical terminology?

Difficulty to swallow → medical terminology?

Back 1

Esophageal pain → Odynophagia

Difficulty to swallow → Dysphagia

Front 2

1. General presentation of esophageael disorders that have any degree of anatomic damage leading to narrowing?

Back 2

a. Dysphagia
b. Weight loss (all forms of dysphagia can lead to weight loss).

Front 3

2. Dysphagia is present, and you do not know the diagnosis, what should you do first?

Back 3

a. Barium study. First.
b. In the stomach, do an endoscopy. First.

Front 4

3. What are the only two esophageal disorders for which endoscopy is indispensable in the diagnosis?

Back 4

a. Cancer
b. Barrett's esophagus (precancerous histologic change). Biopsy is necessary to diagnose both of these.

Front 5

Pathophysiology of Achalasia?

Back 5

Achalasia is the idiopathic loss of the normal neural structure of the lower esophageal sphincter (LES).

Front 6

Achalasia Presentation.

Back 6

Achalasia presents in a young non–smoker who has dysphagia to both solids and liquids at the same time.
1. There may also be regurgitation of food particles and aspiration of previously material that is regurgitated and falls into the lungs.
2. This can be a progressive form of dysphagia in which the symptoms get worse over time.

Front 7

Relationship of Achalasia with alcohol or tobacco use?

Back 7

None.

Achalasia has no relationship with alcohol or tobacco use.

Front 8

Best initial test for achalasia?

Back 8

Barium swallow. (“bird’s beak” at the distal end)

Front 9

Most accurate test for achalasia?

Back 9

Esophageal MANOMETRY.
Endoscopy is NOT the most accurate test. It is done to exclude malignancy.

Front 10

Presentation of achalasia on manometry?

Back 10

Achalasia presents with abnormally high pressure at the lower esophageael sphincter, since it involves a failure of the gastroesophageal sphincter to relax (absence of normal esophageal peristalsis).
There is no mucosal abnormalities.

Front 11

When the Esophagogastroduodenoscopy is answer in pt. with achalasia?

Back 11

1. onset after age 60,
2. anemia,

3. heme-positive stools,

4. >6-month duration of symptoms,

5. weight loss.

Front 12

The best initial therapy in pt. with achalasia?

Back 12

Pneumatic dilation or surgery.

Front 13

What is the risk for pneumatic dilation?

Back 13

risk of perforation 3-5%

Front 14

If the pt. with achalasia not willing to undergo pneumatic dilation, or it has failed, what is the alternative?

Back 14

Botulinum toxin injections into the LES

Front 15

The main limiting factor of Botulinum toxin use in pt. with achalasia.

Back 15

The need for additional injections in a few months.

Front 16

What is the Tx. in pt. with if both pneumatic dilation and botulinum toxin injections fail in pt. with achalasia?

Back 16

surgical myotomy

Front 17

What is the complication of surgical myotomy in pt. with achalasia?

Back 17

reflux in 20%

Front 18

4. Dysphagia + weight loss =?

Back 18

Esophageal pathology

Front 19

5. dysphagia + weight loss + heme–positive stool/anemia =?

Back 19

Cancer

Front 20

7. Cause of Esophageal rings and webs (also known as peptic strictures)?

Back 20

a. Repetitive exposure of the esophagus to acid!
Resulting in scarring and stricture formation.
b. Previous use of sclerosing agents for variceal bleeding can also cause strictures, and this is why variceal banding is a superior procedure.

Neither of them is progressive in nature, distinguishing both of these conditions from achalasia.

Front 21

8. Diagnostic testing for esophageal rings and webs: best initial study?

Back 21

Barium study

Front 22

10. Presentation of Plummer–Vinson syndrome?

Back 22

This is a PROXIMAL stricture found in association with:
1. iron deficiency anemia
2. more common in middle–aged women

Front 23

11. with what condition is Plummer Vinson syndrome associated?

Back 23

Squamous cell esophageal cancer.

Front 24

Schatzki's ring (peptic stricture) pathology and presentation?

Back 24

This is a DISTAL RING of the esophagus that presents with INTERMITTENT symptoms of dysphagia.

Front 25

9. treatment of esophageal rings and webs?

Back 25

Depends on the kind of stricture that presents.

Front 26

12. Best initial therapy for Plummer Vinson syndrome?

Back 26

IRON REPLACEMENT

Front 27

14. Best initial therapy for Schatzki's ring ( peptic stricture).

Back 27

pneumatic dilation.

Front 28

15. What is peptic stricture the results of?

Back 28

Acid reflux.

Front 29

16. Treatment of peptic stricture?

Back 29

Pneumatic dilation.

Front 30

17. Presentation of Zenker's diverticulum?

Back 30

a. Dysphagia with horrible bad breath.
b. There is rotting food in the back of the esophagus from dilation of the posterior pharyngeal constrictor muscles.

c. Difficulty initiating swallowing

Front 31

18. Best initial test for Zenker's diverticulum?

Back 31

Barium study

Front 32

19. best initial therapy for Zenker's diverticulum?

Back 32

Surgical resection

Front 33

What maneuvers are contraindicated with Zenker's diverticulum?

Back 33

Note: to avoid perforation, do not do endoscopy or place a NG tube with Zenker's diverticulum.

Front 34

20. Presentation of diffuse esophageal spasm and “nutcracker esophagus”?

Back 34

Look for a case of severe chest pain, often without the risk factors for ischemic heart disease.
Case may describe the pain is occurring after drinking a cold beverage.
There is ALWAYS pain, but there is not always dysphagia.
The EKG, stress test, and possibly the coronary angiography will be presented as normal.

Front 35

21. Most accurate diagnostic test for diffuse esophageal spasm?

Back 35

a. Manometry
b. barium studies may show a corkscrew pattern, but only during an episode of spasm.

Front 36

What will show manometric studies in pt. with esophageal spasm?

Back 36

High-intensity, disorganized contractions.

Front 37

22. Treatment of esophageal spasm?

Back 37

Calcium channel blockers and nitrates.
The same treatment as for printzmetal's angina.

Front 38

24. How are esophageal disorders similar and different from Prinzmetla's variant angina?

Back 38

They are similar in that the pain is sudden, severe and not related to exercise.
However, Printzmetal's will give you ST segment elevation and an abnormality on stimulation of the coronary arteries, while esophageal spasm will not.

Front 39

25. Presentation of scleroderma (Progressive Systemic Sclerosis)?

Back 39

Acid reflux.

Front 40

LES in scleroderma.

Back 40

The LES will neither contract nor relax and basically assumes the role of an immobile open tube.

Front 41

The most accurate diagnostic test for esophageal scleroderma.

Back 41

motility studies.

Front 42

26. Treatment of Scleroderma?

Back 42

PPIs.

Front 43

27. An HIV–positive man comes in with progressive dysphagia and odynophagia. He has 75 CD4 cells but no history of opportunistic infections. What is the next best step in management?
a. Fluconazole
b. Amphotericin
c. Barium swallow
d. Endoscopy
e. Antiretroviral therapy

Back 43

Answer: A – Fluconazole.
When odynophagia occurs in an HIV–POSITIVE pt, particularlyl when there are <100 CD4 cells, the diagnosis is most likely esophageal candidiasis, and giving empiric fluconazole is both therapeutic as well as diagnostic. Amphotericin is not necessary.

Front 44

28. Presentation of esophagitis?

Back 44

Esophagitis presents with pain on swallowing (odynophagia) as the food rubs against the esophagus.

Front 45

The major difference between the pain of esophagitis and the pain of spastic disorders?

Back 45

In esophagitis, the pain is only on swallowing, whereas with spastic disorders the pain occurs intermittently without even needing to swallow.

Front 46

The most bug in esophagitis?

Back 46

Candida albicans.

When Candida esophagitis occurs, it is almost exclusively in patients who are HIV positive with a CD4 count <200/mm3.

Diabetes mellitus is the second most common risk for developing Candida esophagitis.

Front 47

Other causes of esophagitis?

Back 47

a. Herpes simplex, cytomegalovirus, and aphthous ulcers.

b. Pills, such as doxycycline or a bisphosphonate such as alendronate.
In the case of esophagitis caused by pills. The patient should sit upright and drink more water when taking the pills and remain upright for 30 minutes after taking the pill.

Front 48

29. Diagnostic testing for esophagitis in HIV–negative patients?

Back 48

Endoscopy is done first.

Front 49

30. Diagnostic testing and treatment in HIV–positive patients with less than 100 CD4 cells?

Back 49

a. Give fluconazole.
b. Endoscopy in these patients is performed only if there is no response to fluconazole.

Front 50

31. How common is candida esophagitis in HIV–positive patients?

Back 50

Candida esophagitis causes over 90% of esophagitis in HIV–positive patients.

Front 51

33. Does Mallory–Weiss tear cause dysphagia?

Back 51

No!
Although Mallory–Weiss tear is clearly an esophageal disorder, it does not cause dysphagia.

Front 52

34. Presentation of Mallory–Weiss tear?

Back 52

Sudden upper G.I. Bleeding with violent wrenching and vomiting of any cause.
There may be either hemetemesis or black school.

Front 53

35. Diagnostic testing for Mallory Weiss tear?

Back 53

Diagnosed with an endoscopy.

Front 54

36. Treatment of Mallory Weiss tear?

Back 54

a. Most cases resolved spontaneously.
b. If bleeding persists, injection of epinephrine can be used to stop the bleeding.

Front 55

37. CCS tip: how do I know if I'm doing the right thing on CCS?

Back 55

a. You make a spontaneous nurses notes telling you whether the patient is doing well or not. Get these automatically as the clock forward.
b. You can get an “interval history”as a choice under physical exam.
c. This is a two–minute advance of the clock that will “check in”with the patient. This often tells how the patient is doing and, consequently, how you're doing and management.

Front 56

38. A patient comes with epigastric pain and with associated substernal chest pain and an unpleasant metallic taste in the mouth. What is the next best step in management?

Back 56

a. Proton pump inhibitors. PPIs learn as the first line of therapy and also serve as a diagnostic test.
b. Using PPI's is far easier than other testing.

Front 57

39. Symptoms of GERD other than epigastric pain and substernal chest pain of GERD?

Back 57

1. Sore throat
2. Metallic or bitter taste
3. Hoarsenesss
4. Chronic cough
5. Wheezing
b. As many as 20–25% of those w/chronic cough are suffering from GERD.

Front 58

What factors can cause decreased tone or loosening of this sphincter in GERD?

Back 58

a. Nicotine, alcohol, caffeine, peppermint, chocolate.

b. Anticholinergics, channel blocking agents and nitrates.

c. Simply idiopathic in origin.

Front 59

40. Diagnostic test for GERD?

Back 59

PPI administration is both diagnostic and therapeutic.

Front 60

The most accurate diagnostic test

Back 60

24-hour pH monitor.

But this is only necessary when the patient’s presentation is equivocal in nature and the diagnosis is not clear.

Front 61

41. Treatment of Mild GERD?

Back 61

a. These lifestyle modifications such as:
1. losing weight
2. elevating the head of the bed
3. quitting smoking
4. limiting alcohol, caffeine, chocolate, and peppermint ingestion.
5. Not eating within three hours of sleep.
6. If these do not work, PPIs are the next best therapy for GERD. They should control 90 – 95% of cases. All PPIs are equal in efficacy.

Front 62

42. Efficacy of H2 blockers, such as ranitidine, famotidine, cimetidine, or nizatidine for GERD?

Back 62

a. The control GERD in about two thirds of patients.
b. Hence, they are only used if a PPI is not available.
c. Promotility agents, such as metoclopramide are equal to H2 blockers and are much less effective than PPI's.
d. Therefore, they would not routinely be used.

Front 63

43. What is the cause of 25% of chronic cough?

Back 63

GERD.

Front 64

44. When is reflux alarming, and when is endoscopy used in GERD?

Back 64

In the following symptoms are present:
1. weight loss
2. anemia
3. blood in the stool
4. dysphagia

Front 65

45. What is done for GERD if PPIs are not sufficient to control disease?

Back 65

Surgical or endscopic procedure to narrow the distal esophagus (like Nissen fundoplication).

Front 66

What to do prior to surgery in GERD to avoid iatrogenic dysphagia?

Back 66

motility studies

Front 67

46. Is treatment for H. Pylori effective or necessary for GERD?

Back 67

No.

There is no point in treating Helicobacter pylori without evidence of disease, such as gastritis or ulcer disease.

Front 68

49. What is the risk of Barret esophagus transforming to esophageael cancer?

Back 68

a. 0.5% of cases per year will transform into esophageal cancer.
b. This is why adenocarcinoma is an increasingly frequent histological type of esophageal cancer.

Front 69

50. Diagnostic testing for Barrett esophagus?

Back 69

a. Endoscopy– in which you are able to visualize and biopsy the distal esophagus.
b. Barrett esophagus is a biopsy diagnosis.
c. Although the colorwhen to perform is different, the only way to be certain that the histology is changed from squamous epithelium to columnar epithelium is by endoscopy biopsy.

Front 70

51. When should you perform endoscopy in GERD pt.?

Back 70

a. Weight loss
b. Anemia
c. Heme–positive stool
d. Anyone with symptoms of reflux disease for more than 5– 10 years.

Front 71

52. What is the Tx. if endoscopic finding are Barrett esophagus? And when should we repeat endoscopy?

Back 71

PPI and repeat endoscopy every two – three years.

Front 72

53. What is the Tx. if endoscopic finding are low–grade dysplasia? And when should we repeat endoscopy?

Back 72

PPI and repeat endoscopy every three – six months.

Front 73

54. What is the Tx. if endoscopic finding are high–grade dysplasia? And when should we repeat endoscopy?

Back 73

a. Endoscopic mucosal resection
b. ablative removal
c. distal esophagectomy.

Front 74

Adenocarcinoma vs squamous cell carcinoma in esophageal cancer?

Back 74

Adenocarcinoma - in the distal third of the esophagus.

Squamous cell cancer - in the proximal two-thirds of the esophagus.

Squamous and adenocarcinoma are
now of equal frequency.

Front 75

Etiology of Esophageal squamous cell carcinoma?

Back 75

Linked to the synergistic, carcinogenic effect of alcohol and tobacco use.

Front 76

Etiology of Adenocarcinoma in Esophageal cancer?

Back 76

Long-standing gastroesophageal reflux disease and Barrett esophagus.

Front 77

First test in esophageal cancer?

Back 77

barium swallow.

Front 78

What is the best test for esophageal cancer?

Back 78

endoscopy for tissue biopsy.

Front 79

What test detects the degree of local spread for esophageal cancer?

Back 79

CT

Front 80

What test detects asymptomatic spread into the bronchi in pt. with esophageal cancer?

Back 80

bronchoscopy.

Front 81

What test is performed for staging of esophageal cancer?

Back 81

Endoscopic ultrasound

Front 82

What is the best initial therapy for esophageal cancer?

Back 82

Surgical resection.

Surgery is performed if there are no local or distant metastases.

Front 83

Survival rate in Surgical resection for esophageal cancer?

Back 83

Five-year survival is between 5 and 20%.

Front 84

What is the Tx. of esophageal cancer to control
locally metastatic disease?

Back 84

5-fluorouracil-based chemotherapy combined with radiation.