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11 Cards in this Set

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A 27-year-old pharmacist presents for her annual physical examination. She describes that over the past several months she has awoken from sleep on several occasions with cough, wheezing, and shortness of breath, but denies having these symptoms during the day. The symptoms generally last for up to 2 hours before gradually subsiding. She has no previous history of asthma and exercises regularly without difficulty. She is on no medications, except for the frequent use of over-the-counter histamine-2 receptor antagonists for daily episodes of heartburn. She is afebrile and has normal vital signs. Her lungs are clear to auscultation and percussion. Which of the following is the most likely explanation for her nocturnal symptoms?

A. Acid reflux
B. Laryngospasm
C. Mast cell release
D. Mucus plugs
E. Upper airway obstruction
The correct answer is A. This patient has typical symptoms of the extra-esophageal manifestations of gastroesophageal reflux disease (GERD). At night, while she is supine, acid may reflux across the upper esophageal sphincter and into the upper airway, triggering bronchoconstriction and her asthmatic symptoms. The history of GERD is suggested by her baseline symptoms of heartburn requiring histamine-2 receptor antagonists. The treatment for these patients is acid reduction directed at the underlying GERD process.

Laryngospasm (choice B) does not present with cough and wheezing, but with hoarseness and stridor.

Mast cell release (choice C) is the mechanism whereby exercise-induced asthma occurs.

Mucus plugs (choice D) can occur in patients with copious secretions, which may cause transient airway obstruction.

Upper airway obstruction (choice E) may occur during sleep in patients with sleep apnea, but there are no signs or symptoms to suggest this syndrome in this patient.
A 31-year-old man reports 9 months of difficulty swallowing his meals. The symptoms have caused him to lose weight, and he has been waking in the middle of the night with recurrent coughing. He has had difficulty swallowing solids as well as liquids since these symptoms began. An esophagram reveals a dilated esophagus with a smoothly tapered distal esophagus. Which of the following manometric findings would most likely be found in this patient?

Peristalsis in body of esophagus pressure Resting lower esophageal sphincter (LES)
A. Decreased Normal
B. Decreased Increased
C. Increased Decreased
D. Decreased Decreased
E. Increased Increased
The correct answer is B. This patient has achalasia, which is a neurogenic esophageal disorder thought to be related to a malfunction of the myenteric plexus of the esophagus. The result is that the esophagus behaves as if it has lost the normal peristaltic mechanism. There is also an accompanying failure to relax the lower esophageal sphincter (LES) when food reaches the distal esophagus. Because of these problems, patients experience difficulty with swallowing both solids and liquids. This is in contrast to masses of the esophagus that cause lumenal narrowing, in which the swallowing of liquids is at least initially relatively preserved. Manometry of patients with achalasia typically shows decreased peristalsis in the body of the esophagus with reduced resting LES pressure. These patients often have nocturnal coughing because of aspiration of retained food contents within the esophagus.

Choices A and C are not typical of any condition you need to remember.

Choice D is typical of severe esophageal disease in scleroderma.

Choice E is typical of symptomatic diffuse esophageal spasm.
A 22-year-old pregnant woman develops the gradual onset of severe low back pain during her 10th week of pregnancy. She begins taking ibuprofen for control of her symptoms. She has previously had a bleeding ulcer and was prescribed misoprostol, which she began taking to prevent ulcer recurrence. Forty-eight hours later, she has severe vaginal bleeding, and it is determined that she has had a completed abortion. Which of the following is the most likely explanation for this occurrence?

A. Antiphospholipid-induced thrombosis
B. Cyclooxygenase-induced uterine contractions
C. Factor VIII deficiency(induced hemorrhage
D. Lipoxygenase-induced uterine contractions
E. Prostaglandin-induced uterine contractions
The correct answer is E. This patient has taken the prostaglandin misoprostol, which is designed to prevent ulcer occurrence with the use of NSAIDs. It is strictly prohibited during pregnancy since it has the predictable effect of inducing uterine smooth muscle contractions. This has actually become part of an "at-home" abortion method using the combination of oral methotrexate and misoprostol.

Antiphospholipid antibodies (choice A) may induce thrombosis of placental vessels and cause recurrent second-trimester abortions. However, there is no history to suggest this diagnosis in this patient.

Cyclooxygenase and lipoxygenase (choices B and D) are enzymes that are involved in arachidonic acid metabolism.

Similarly, there is no evidence given to suggest an underlying factor VIII deficiency (choice C).
A 34-year-old woman complains of difficulty swallowing both liquids both solids for the past 6 months. She has a history of hypertension and Raynaud phenomenon. A physical examination reveals tight skin on her face and on the dorsal surfaces of both hands. Which of the following manometric findings would most likely be found in this patient?

Peristalsis in body of esophagus pressure Resting lower esophageal sphincter (LES)
A. Decreased Normal
B. Decreased Increased
C. Increased Decreased
D. Decreased Decreased
E. Increased Increased
The correct answer is D. Scleroderma (progressive systemic sclerosis) is an important disease in which a variety of body tissues can undergo fibrosis. The most obvious of these is the skin, which produces the tight thick skin seen on this patient's hands and face. Internally, the esophagus is particularly susceptible to this fibrotic process, which will destroy the ability of the esophagus to undergo peristalsis, because of both the loss of muscle and the stiffening by fibrosis. Typical manometric findings in these patients are diminished or absent peristalsis in the body of the esophagus with a greatly reduced resting lower esophageal sphincter (LES) pressure. Scleroderma patients are at significant risk for severe gastroesophageal reflux disease (GERD) and its complications.

Choices A and C are not typical of any condition you need to remember.

Associate the findings illustrated in Choice B with achalasia.

Associate the findings illustrated in Choice E with symptomatic diffuse esophageal spasm.
A 37-year-old woman presents with complaints of severe heartburn with or without meals. She has a history of hypertension, which has been treated with captopril. She also has a history of Raynaud disease, multiple facial telangiectasias, and very taut skin on the dorsum of both hands. She has failed to obtain relief for her heartburn with large doses of antacids, ranitidine, or omeprazole. Esophageal manometry is ordered. Which of the following would be the most likely results of this test?

A. Decreased esophageal peristalsis and decreased LES pressure
B. Decreased esophageal peristalsis and increased LES pressure
C. Increased esophageal peristalsis and decreased LES pressure
D. Increased esophageal peristalsis and increased LES pressure
E. Normal esophageal peristalsis and normal LES pressure
The correct answer is A. This patient has the classic presentation of gastroesophageal reflux disease (GERD) in association with scleroderma. These patients have the deposition of collagen in the body of the esophagus, as well as the lower esophageal sphincter (LES). This results in the typical pattern of decreased esophageal peristalsis and the reduced ability of the LES to maintain its high pressures between swallowing. These patients are therefore at risk for severe GERD and subsequent complications of peptic stricture and Barrett's esophagus. Although there is no corrective therapy to improve esophageal motility or increase LES pressure, aggressive treatment is generally aimed at reducing acid production with the use of high doses of proton pump inhibitors. Nevertheless, many of these patients develop the long-term consequences of GERD.

Choice B suggests achalasia, in which impaired esophageal peristalsis is often accompanied by a lack of lower esophageal sphincter relaxation.

Choice C doesn't describe any of the more common esophageal motor disorders.

Choice D suggests symptomatic diffuse esophageal spasm, particularly if the peristaltic waves were poorly organized.

Choice E would be seen in patients without esophageal motor disease.
A patient with a history of hypertension calls his physician's office for advice. He has had longstanding heartburn and recently consulted with a gastroenterologist. He underwent an endoscopy and was told that "Barrett's mucosa" was found by biopsy. The patient has read in the newspaper that people with this condition will probably develop esophageal cancer. Which of the following is the most appropriate response to this concern?

A. "Your concerns are ungrounded"
B. "It is foolish to worry because this type of cancer is unlikely to develop and would occur many years later"
C. "You should chew food very carefully to prevent the possibility of a mechanical obstruction"
D. "Only a small minority of patients with Barrett's esophagus will develop cancer, and you should undergo endoscopic surveillance"
E. "You should consult with an oncologist regarding esophageal cancer prevention strategies"
The correct answer is D. Barrett's esophagus may occur in a small number of patients who have gastroesophageal reflux disease (GERD). This condition is a metaplasia of the normal squamous mucosa of the esophagus to a columnar (glandular) type of epithelium, and is usually seen as a response to repeated acid exposure to the distal esophagus. Tobacco and alcohol use are also thought to contribute to the process. The significance of Barrett's esophagus is that it may lead to the development of low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma. However, this is a very infrequent occurrence when considering the large number of patients with GERD and even those with Barrett's esophagus. Barrett's esophagus usually does not resolve with either medical or surgical therapy. Endoscopic surveillance (with multiple small biopsies, since dysplasia cannot be reliably evaluated by endoscopic appearance alone) every 1-2 years has been often recommended, but some studies suggest that it may not be cost-effective.

It is not factually true to inform the patient that his concerns are "ungrounded" (choice A), because there is in fact a small risk of adenocarcinoma.

It is never appropriate to belittle a patient's concerns and inform him that his worries are "foolish" (choice B).

Barrett's esophagus is a histologic change and, unless accompanied by a stricture, does not produce symptoms of mechanical dysphagia (choice C).

It is inappropriate to refer the patient to a cancer specialist (choice E) for the prevention of a very unlikely development of cancer; furthermore, preventive strategies should include instructions to avoid factors that exacerbate GERD and should be delivered to the patient by the primary care physician.
A 69-year-old man in the cardiothoracic intensive care unit is postoperative day 6 for a coronary artery bypass graft. He was initially extubated on postoperative day 1, but was then re-intubated the following day for aspiration pneumonia, which had worsened despite administration of IV penicillin and gentamicin. He is also receiving daily furosemide, aspirin, and subcutaneous heparin 5000 units. One hour ago, he passed a large volume of black tarry stool. His temperature is 38.9 C (102 F), blood pressure is 180/94 mm Hg, and pulse is 102/min. Loud rhonchi are heard bilaterally. He has a regular, rapid heart rhythm with a II/VI systolic murmur. His abdomen is soft with mild epigastric tenderness. No masses are palpable. Rectal examination reveals no masses, and melena is present. Laboratory studies show a leukocyte count of 14,400, a hemoglobin of 9.8 g/dL, and a hematocrit of 29%. Which of the following is the most likely source of this patient's bleeding?

A. Cecal arterial venous malformations
B. Diffuse gastritis
C. Erosive esophagitis
D. Esophageal varices
E. Giant gastric ulcer
The correct answer is B. This scenario is the classic situation for the development of diffuse stress gastritis, which has resulted in a large volume, black tarry stool. Furthermore, the patient is on aspirin and heparin, which predispose to bleeding from stress gastritis.

Cecal arterial venous malformations (choice A) are a common cause of bleeding in the elderly, but generally present with lower gastrointestinal bleeding with either hematochezia or maroon stool.

Although erosive esophagitis (choice C) may also occur in the critically ill patient, it is not as common as diffuse stress gastritis.

There is no evidence that the patient has esophageal varices (choice D), and patients in this setting are not at particular risk for a single giant gastric ulcer (choice E).
A 34-year-old bus driver presents with complaints of difficulty swallowing. The symptoms began gradually, approximately 9 months ago, and have prevented him from chewing solids or drinking liquids comfortably. He finds himself awakened at night with cough and occasional morning regurgitation of recognizable food from the night before. He has learned to reduce his oral intake and has lost 6 pounds over the past 2 months. He does not smoke or drink and has no family history of esophageal or other gastrointestinal illnesses. His physical examination is unremarkable. Which of the following is the most likely diagnosis?

A. Achalasia
B. Esophageal adenocarcinoma
C. Lower esophageal web
D. Peptic stricture
E. Progressive systemic sclerosis
The correct answer is A. The diagnosis of a motility disturbance, rather than a mechanical cause for dysphagia, is suggested by the history of difficulty with swallowing both solids and liquids at the onset of his symptoms. Achalasia is characterized by markedly reduced or absent peristaltic waves in the body of the esophagus and an increased resting pressure at the lower esophageal sphincter (LES) that fails to relax with swallows. This results in stasis of food within the esophagus, which can be regurgitated, even aspirated, and lead to aspiration pneumonias. The underlying disease process in achalasia appears to be a malfunction of the myenteric plexus of the esophagus, which in turn leads to denervation of the esophageal musculature. Forceful dilation of the LES is often initially helpful in relieving the obstruction and pressure within the esophagus, but may have to be repeated periodically as obstruction often recurs. The addition of sublingual nitroglycerine or calcium channel blockers that tend to relax the LES may increase the time between dilations. Some patients are eventually treated with either a Heller myotomy or injection of botulinum toxin into the LES. Rare cases of achalasia are complicated by esophageal rupture with secondary mediastinitis.

Esophageal carcinoma (choice B) may occur in patients with a history of Barrett's esophagus secondary to longstanding GERD. It, too, produces a mechanical-type dysphagia. In any case, this patient is far younger than the typical patient who develops esophageal adenocarcinoma seen later in life.

A lower esophageal web (choice C), also referred to as a Schatzki ring, produces episodic dysphagia to large solids that are greater in diameter than the size of the ring.

A peptic stricture (choice D) presents with a mechanical-type dysphagia. The dysphagia initially affects large solids, and then gradually worsens to smaller, softer foods, and eventually liquids. It usually occurs in patients with a longstanding history of GERD.

Progressive systemic sclerosis (PSS) (choice E) is far more likely to occur in women. It, too, causes a motility disturbance of the esophagus and, like achalasia, has reduced or absent motility in the body of the esophagus. In PSS, however, there is reduced LES pressure at rest that predisposes to severe GERD and its possible sequelae. Unless there are symptoms of a mechanical obstruction secondary to a stricture, esophageal retention of food does not occur.
A 41-year-old man presents with complaints of mild intermittent heartburn after meals for the past 6 months. He has tried various over-the-counter antacids and H2 receptor antagonists with only minimal relief. He denies any dysphagia or odynophagia, and is otherwise in good health. He is concerned about the risk of developing cancer, because his father died of gastric cancer at age 49. His physical examination is unremarkable. Which of the following would be the most appropriate next step in management?

A. Avoidance of a high-protein diet
B. Avoidance of aspirin
C. Avoidance of acetaminophen
D. Elevation of the head of his bed
E. Increased consumption of carbohydrates
The correct answer is D. Before initiating pharmacologic therapy, it is worthwhile to consider lifestyle modifications that may reduce symptoms in patients with gastroesophageal reflux disease (GERD). In this regard, elevating the head of his bed is an important step, since it will reduce the degree of nocturnal acid reflux while the patient is in the supine position. Other nonpharmacologic measures that may be helpful include avoidance of strong stimulants of acid secretion (coffee, alcohol), avoidance of certain drugs (anticholinergics) and foods (fats, chocolates), and cessation of smoking.

Although fatty foods may exacerbate GERD by reducing the pressure on the lower esophageal sphincter (LES), high-protein diets (choice A) and carbohydrates (choice E) have no particular effect on the mechanism or symptoms or GERD.

Although aspirin (choice B) may be injurious to the gastric and duodenal mucosa, it is not implicated in exacerbations of GERD.

Acetaminophen (choice C) has no effect on the symptoms or cause of GERD.
A 39-year-old woman presents with complaints of difficulty swallowing. She has a history of scleroderma for the past 15 years, during which time she has required a variety of medications to reduce the symptoms of heartburn. Over the past 6 months, she has also noted difficulty swallowing food, such as steak, and has felt as if food "sticks" in her lower chest. She is able to tolerate liquids without difficulty. She denies any weight loss. Which of the following has most likely occurred?

A. Development of a squamous carcinoma in the upper third of the esophagus
B. Recent return of peristaltic activity in the body of the esophagus
C. Reverse peristalsis in the body of the esophagus
D. Reverse peristalsis of the lower esophagus
E. Scarring at the lower esophagus because of chronic acid reflux
The correct answer is E. This patient has a history of scleroderma, which can cause esophageal dysfunction secondary to fibrosis. Patients with scleroderma are very vulnerable to acid reflux because neither peristalsis nor the lower esophageal sphincter function normally after much of the muscle tissue has been replaced by fibrosis. The situation is complicated by the fact that persistent acid reflux will eventually itself induce scarring with formation of a peptic stricture in the distal esophagus. Care should be taken to carefully manage even mild reflux symptoms in patients with scleroderma to prevent (or at least to slow) the development of this troubling complication.

Although chronic acid reflux can predispose for Barrett's esophagus, with the risk of progression to adenocarcinoma of the distal esophagus, squamous carcinoma of the upper third of the esophagus (choice A) would not be an expected complication.

Once peristalsis is lost, there is almost never a return of peristaltic activity (choice B).

Reversed peristalsis (choices C and D) is not usually seen clinically. Disordered peristalsis can be seen in symptomatic diffuse esophageal spasm.
A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing a tight belt, or lying flat in bed at night. He gets symptomatic relief from over-the-counter antiacids or H2 blockers, but has never been formally studied or treated. The problem has been present for many years and seems to be progressing. Which of the following is the most appropriate next step in management?

A. Barium swallow
B. Cardiac enzymes and ECG
C. Proton pump inhibitors
D. Endoscopy and biopsies
E. Laparoscopic Nissen fundoplication
The correct answer is D. The clinical picture is fairly convincing for long-standing gastroesophageal reflux. The main concern is the degree of peptic esophagitis that he may have developed, and the possibility of Barrett's esophagus and premalignant changes. Endoscopy and biopsies will provide the answer.

Barium swallow (choice A) would provide anatomic evidence of hiatal hernia and evidence of reflux, but would not tell us whether Barrett's esophagus has developed.

Cardiac enzymes and ECG (choice B) would be part of the work-up (along with pH monitoring) if we were uncertain as to the genesis of ill-defined low retrosternal and upper epigastric pain. This man gives a classic presentation for reflux.

Proton pump inhibitors (choice C) might likewise be indicated for this man, but not until we know the severity and potential premalignant stage of his disease.

Nissen fundoplication (choice E) may some day be needed here, but one would not jump to a surgical solution based only on a clinical presentation.