Diagnostic evaluation of the eosphagus Flashcards
The most common cause for failure of anti-reflux surgery?
A. Poor surgical Technique
B. Poor compliance
C. Poor Patient selection
D. idiopathic
Ans C - the most common cause of failure after antireflux surgery is poor patient selection.
Shackleford 8e Pg 44.
Most common presenting complaint of esophageal cancer?
A. Hematemesis
B. Dysphagia
C. Weight Loss
D. Bloating
Ans B - dysphagia is the most common presenting symptom associated with esophageal cancer
Shackleford 8e Pg 44.
Which of the following is not true regarding sensory innervation of esophagus
A. Low threshold tension sensitive fibers are carried by Vagus nerve. They contribute to physiologic reflexes.
B. Nociception function is via the spinal nerves including distension and acid exposure.
C. Most fibers respond only to mechanical sitmuli
D. Sensory nerve fibers are present in both muscle and mucosa.
Ans C -
Most fibers respond to both mechanical and chemical stimuli,
While vagus nerves carry the low threshold tension sensitive fibers which are involved in physiologic reflexes, the spinal nerves carry the nociceptor functions.
Sensory nerve fibers are present in both muscle and mucosa.
Shackleford 8e Pg 44.
Which of the following is an incorrect statement regarding the sensation of esophagus ?
A. TRPV1 channels mediate the heart burn in NERD
B. TRPV1 channels are also involved in neurogenic inflammation
C. Visceral hypersensitivity in patients with NERD appears to involve neurogenic inflammation.
D. Neurokinin 1 receptors and Substance P are increased in Visceral hypersensitivity and activate TRPV1
Ans A
Acid sensing ion channels are involved in the heartburn in non-erosive reflux disease.
B, C and D are true statements.
Shackleford 8e Pg 44.
Bernstein test involves ?
A. Acid infusion in esophagus
B. Fecal fat estimation in chronic pancreatitis
C. rate of solid food emptying in stomach
D. rate of water absorption in colon.
Ans A - Acid infusion in the esophagus is tested using the bernstein test.
Shackleford 8e Pg 44.
which of the following is not an atypical symptom of GERD?
A. Dental Caries
B. Globus sensation
C. Dysphagia
D. Noncardiac Chest pain
Ans C -
Typical symptoms of GERD include heartburn and regurgitation. (Some authors include dysphagia)
atypical symptoms include non-cardiac chest pain, chronic cough and asthma, Hoarseness and dental caries, nausea and vomiting and globus sensation.
Shackleford 8e Pg 45.
most common esophageal symptom of GERD ?
A. Regurgitation
B. Heartburn
C. Dysphagia
D. Burning sensation in epigastrium
Ans B - Heartburn is the most common esophageal symptom of GERD.
Shackleford 8e Pg 45.
what percentage of western population experiences weekly symptoms of heartburn?
A. 10-20%
B. 20-30%
C. 40-50%
D. 60%
Ans B - 20-30%
Upto 60% of western population experience heartburn atleast once every year, and 20-30% have weekly symptoms.
Shackleford 8e Pg 45.
Which of the following statements is Not true regarding Functional heartburn ?
A. Treatment is done using antidepressants
B. Antireflux surgery has good results.
C. Impedance study is necessary to confirm the diagnosis
D. 30% of patients PPI-refractory disease have functional heartburn
E. Visceral hypersensitivity is the possible mechanism
Ans B -
Antireflux surgery has poor results in this scenario since the symptoms are a result of visceral hypersensitivity and not associated with reflux.
Shackleford 8e Pg 45.
which of the following statements is true regarding globus sensation?
A. Have a significant association with GERD
B. Need more prolonged and intensive trial of PPI than heartburn.
C. Anti-reflux surgery is a viable option for treatment of globus sensation alone.
D. most common in fifth and sixth decades
E. exacerbations associated with emotional intense states.
Ans C -
Anti-reflux surgery should not considered a viable option for the treatment of globus sensation alone.
Shackleford 8e Pg 48.
PPI should be stopped for what period before taking a 24h pH test for GERD?
A. Can be continued.
B. 2 days
C. 5 days
D. 7 days
Ans D -
PPI should be stopped 7 days prior.
Histamine blockers should be stopped 48 hours prior.
Over the counter antacids can be continued up until the time of study.
Shackleford 8e Pg 49.
All of the following conditions may obviate the need for pH testing except.
A. Obviously defective LES on manometry.
B. Obvious esophagitis on endoscopy
C. very large para-esophageal hernia
D. chronic cough
Ans D - Chronic cough.
Shackleford 8e pg 49,50.
what is the duration of the refractory period of the esophagus?
A. 10s
B. 20s
C. 30s
D. 40s
Ans B - 20s.
The refractory period of the esophagus, as swallows closer together than 20s may have poorer quality propulsive function .
Shackleford 8e Pg 50.
Endoscopy showing mucosal break that is continuous between the tops of two mucosal folds, and involves 75% of the circumference is what grade of esophagitis as per Los Angeles Classification
A. Grade A
B. Grade B
C. Grade C
D. Grade D
ans D - Grade D
Grade A - one or more mucosal breaks upto 5mm in length. Not extending between the tops of two mucosal folds.
Grade B - one or more mucosal breaks more than 5mm in length. Not extending between the tops of two mucosal folds.
Grade C - one or more mucosal breaks that is continuous between the tops of two or more mucosal folds, but which involve less than 75% of the circumference.
Grade D - one or more mucosal breaks involves 75% or more of the esophageal circumference.
Shackleford 8e Pg 51.
which radiotracer used in scintigraphy with standardized meal of radiolabelled low fat egg whites to assess for delayed gastric emptying ?
A. Se
B. In
C. I-131
D. Tc99
ans D - Tc99m is used for delayed gastric empyting studies using standardized meal of radiolabelled low fat egg whites.
The study is done over 4 hours.
Shackleford 8e Pg 52.
which of the following is not mandatory during a work up of Paraesophageal hernias?
A. pH studies
B. Barium studies
C. Endoscopy
D. Manometry
Ans A -
Most patients’ symptoms progress slowly and an outpatient workup can be performed. This work-up should include barium studies, endoscopy, and manometry.
pH studies are likely un-necessary as the indication for surgery is large hernia itself.
Barium studies will show the size and position of the hernia and if performed with a 13mm tablet, will reveal any delay during passage.
Endoscopy will identify Barrett Esophagus, dysplasia and Cameron ulcers in the stomach.
Manometry will identify marked motility abnormalities.
Shackleford 8e Pg 52.
Cameron ulcers are typically related to ?
A. Burns
B. Head injury
C. Hiatal hernia
D. both B and C
Ans C - hiatal hernia.
Shackleford 8e Pg 52.
Which of the following statements is true?
A. Dysphagia usually occurs in esophageal cancer when 50% of the circumference is involved or diameter is less than 12mm
B. Anti-reflux surgery in lung transplant patients with GERD is preferably performed after the transplant.
C. GERD is a contributor to the development of Bronchiolitis Obliterans syndrome after lung transplant.
D. Manometry, pH studies and Barium esophagogram are mandatory in patients with Paraesophageal hernia
Ans C
Dysphagia usually occurs in esophageal cancer when more than 60% of the circumference is involved or when the diameter is less than 12mm.
Anti-reflux surgery is preferably performed before the transplant when the patient can recover better in the absence of immunosupression if they can tolerate it.
However if not performed before the transplant, it should be taken up during first 6 months after the transplant, since once the FEV1 starts to reduce the condition becomes irreversible.
Manometry, Endoscopy and Barium Esophagogram is needed in patients with paraesophageal hernia.
Shackleford 8e Pg 53,54.
First investigation in evaluation of dysphagia?
A. Barium Esophagogram
B. Endoscopy
C. Manometry
D. pH studies
Ans A - Barium Esophagogram
the relatively low cost and almost universal availability make them a logical starting point for the evaluation of dysphagia.
Shackleford 8e Pg 57.
which part of the esophagus has the lowest normal contractile amplitude?
A. Cricopharyngeal
B. Proximal thoracic
C. Middle thoracic
D. Distal thoracic
Ans C -
Frequently a small amount of barium remains in the middle 1/3 of the esophagus after the passage of the primary peristaltic wave. This small residual volume should not be interpreted as abnormal motility since this esophageal segment is normally the zone of lowest normal contractile amplitude.
Shackleford 8e Pg 59.
all of the following are used to differentiate normal Esophageal ampulla from a hiatal hernia except -
A. Smooth margins, mildly dilated segment
B. Absence of gastric folds
C. Presence of normal peristalsis
D. Feline esophagus
Ans D -
The normal esophageal ampulla or vestibule is sometimes confused with a hiatal hernia. It appears as a smoothly marginated, mildly dilated segment of the esophagus just superior to the esophageal hiatus. Unlike a hiatal hernia, the ampulla does not contain gastric folds and will demonstrate typical esophageal persitalsis.
The transient appearance of fine, evenly spaced, transverse folds is called Feline esophagus. This condition has been reported to be more frequent in patients with GERD but is also demonstrated in asymptomatic patients. Thought to result from the contraction of the longitudinal muscle layer of the esophagus, usually in response to GER.
Shackleford 8e Pg 60
Criteria for the diagnosis of GER on 24h Ambulatory pH study
A. pH of less than 4 for more than 5% of the 24 hour monitoring period
B. pH of less than 4 for more than 15% of the 24 hour monitoring period
C. Longest episode of pH <4 lasting more than 10 minutes.
D. lowest pH less than 2.5 for any duration
Ans A -
A pH of less than 4 during greater than 5% of the 24 hour monitoring period is considered a positive test.
Shackleford 8e Pg 61.
larger diameter strictures and those that taper gradually are best seen on
A. Air contrast esophagogram
B. Mucosal Relief images
C. Single contrast esophagogram
D. None of the above
Ans C - single contrast evaluation of the esophagus in the prone position is superior to endoscopy for detecting areas of segmental esophageal narrowing especially largery diameter strictures and those that taper gradually.
They may not be appreciated on endoscopy, particuarly with smaller diameter endoscopes.
Many esophageal strictures and rings may be missed if the esophagogram is done only in the upright position.
Shackleford 8e Pg 61
Reticular mucosal pattern on esophagogram is typically said to be associated with
A. GERD
B. Hiatal hernia
C. Barrett’s esophagus
D. achalasia
Ans C - Barrett’s esophagus.
Found to be present in 23% cases. The findings of hiatal hernia, GER, and esophageal stricture are better clues to the presence of barrett’s esophagus than the reticular mucosal pattern described initially.
Shackleford 8e Pg 62.
Large hiatal hernia is defined as -
A. more than 2cm
B. more than 5cm
C. more than 10cm
D. more than 15cm
Ans B - more than 5cm.
Shackleford 8e pg 62.
best investigation to estimate the size of a hiatal hernia ?
A. Endoscopy
B. Barium esophagogram
C. CECT Chest with gastrograffin swallow
D. none of the above
Ans B -
Size of the hiatal hernia is best estimated during a barium study. Hernia size is determined by measuring the distance from the GEJ to the esophageal hiatus during maximum filing of the hernia in the prone position.
Shackleford 8e Pg 63.
which of the following statements is True regarding hiatal hernia?
A. Endoscopy tends to underestimate the size of the hiatal hernia
B. Barium esopphagogram in upright position is the best to estimate the size of the hiatal hernia
C. Esophageal shortening is the result of transverse due to severe GERD scarring.
D. Hiatal hernia with bulging shoulders is suggestive of shortening.
Ans A -
Endoscopy tends to underestimate the size of the hiatal hernia since the hernia is partially reduced during the passage of the scope into the stomach.
Hernia size is determined by measuring the distance from the GEJ to the esophageal hiatus during maximum filling of the hernia in the prone position
Esophageal shortening is the result of longitudinal scarring.
Hiatal hernia with tapering shoulders rather than bulging is suggestive of shortening of the esophagus.
Shackleford 8e Pg 63.
Esophagogram has the highest sensitivity for which of the following?
A. Jackhammer esophagus
B. DES
C. Non-specific Esophageal motility disorder
D. Achalasia Cardia
Ans D -
The examination is very sensitive for the detection of achalasia (95%), it is less sensitive for DES (71%) and non specific esophageal motility disorders.
Shackleford 8e pg 63.
which of the following statements is not true ?
A. Higher the level of the barium column in achalasia, more severe is the disease.
B. length of the bird beak is greater in patients with achalasia compared to pseudoachalasia
C. level of the distal esophagus may be lower than the level of the GEJ in sigmoid esophagus.
D. prominent tertiary contractions in the distal esophagus with tapered GEJ is suggestive of vigorous achalasia.
Ans B -
Length of the bird’s beak is longer in patients with pseudoachalasia as compared to classic achalasia.
Shackleford 8e pg 63, 64.
Corkscrew appearance of esophagus is characteristic of ?
A. Diffuse esophageal Spasm
B. Jackhammer esophagus
C. Achalasia cardia
D. GERD
Ans A - DES.
Shackleford 8e Pg 64.
Normal thickness of the esophageal wall in CT
A. 3.5 mm or less
B. 5.5 mm or less
C. 4.5 mm of less
D. 2.5 mm of less
Ans B - 5.5 mm or less.
thickening of the distal esophageal wall by thoracic CT scans has been reported in 21% of patients with DES. The thickness of the esophageal wall by CT in normal subjects should not exceed 5.5 mm. Therefore DES should be considered in a differential diagnosis of concentric distal esophageal wall thickening by CT along with infectious, inflammatory and neoplastic causes.
Shackleford 8e Pg 64.
advanced Scleroderma resembles which of the following on esophagogram
A. Barrett’s esophagus
B. Achalasia Cardia
C. Schatzki’s ring
D. Carcinoma Esophagus
Ans B -
Esophageal scleroderma results in distal esophageal scarring, an esopahgeal shortening resulting in proximal dilation, distal stricture, and hiatal hernias with tapered rather than shouldered margins.
When esophageal scleroderma reaches such advanced stage it can be difficult to distinguish from achalasia because of the similar radiographic picture of poor esophageal peristalsis, distal sclerosis and proximal dilation.
Shackleford 8e Pg 65.
which of the following have similar radiologic appearance on barium studies to classic achalasia?
A. Chagas disease
B. Advanced scleroderma
C. Esophageal neoplasm
D. All of the above
Ans D - all of the above.
The radiographic appearance of esophageal chagas disease is identical to classic achalasia.
When esophageal scleroderma reaches the advanced stage, it can difficult to distinguish from achalasia.
Esophageal neoplasm can present with pseudoachalasia which can be nearly indistinguishable from classic achalasia.
Shackleford 8e Pg 64, 65.
Criteria for identifying metastatic lymph nodes in mediastinum on CT ?
A. long axis longer than 1cm
B. Short axis longer than 1cm
C. Short axis longer than 0.5cm
D. Both A and C
Ans B -
Short axis diameter greater than 1cm will represent metastatic adenopathy in the setting of known esophageal cancer.
Shackleford 8e Pg 68.
which of the following statements is true regarding role of MRI in Ca Esophagus?
A. most common problem of MRI is motion artefact
B. Has no routine role in esophageal cancer staging.
C. most of the same advantages and disadvantages as CT
D. All of the above.
Ans D - All of the above.
Shackleford 8e Pg 68.
PET/CT is most useful in diagnosing which of the following stages of Ca Esophagus ?
A. T4b
B. N3
C. M1a
D. M1d
Ans C - M1a
Relative to nodal disease, identification of M1a disease can be difficult without the use of CT fusion imaging to provide anatomic guidance on location of the celiac axis. For M1b disease, CT fusion with PET may not be as important but can help in locating metastases.
Shackleford 8e Pg 69.
which of the following is true statements regarding Ca Esophagus ?
A. Therapeutic tumor response can be detected using PET as early as 10 days into therapy.
B. Cutoff value for reduction in tumor metabolism was set at 25%.
C. In suspected recurrence, CT is the most sensitive evaluation.
D. patients who failed to show a metabolic response on PET had a shorter time to progression or recurrence and decreased Overall Survival.
Ans D
A - therapeutic tumor response can be detected using PET as early as 14 days after neoadjuvant therapy.
B. Cutoff value for reduction in tumor metabolism was set at 35%
C. In suspected recurrence, PET imaging has been shown to be more sensitive than evaluation by CT and EUS.
Shackleford 8e Pg 70.
Most common esophageal neoplasm ?
A. Leiomyoma
B. Melanoma
C. GIST
D. Lipoma
Ans A -
Benign neoplasms of the esophagus are rare, with the exception of Leiomyoma which is the most common esophageal neoplasm.
Shackleford 8e pg 70.
Leaks are most common after which esophageal surgery?
A. Diverticulectomy
B. Myotomy
C. Esophagectomy
D. A and B
Ans C -
Leaks can occur after any esophageal surgery but they are most common after esophagectomy.
Shackleford 8e Pg 73.
high density barium is
A. 100% w/v
B. 150% w/v
C. 200% w/v
D. 250% w/v
Ans D - 250% w/v
small leaks can only be detected by the use of high density barium.
Shackleford 8e Pg 73.
which of the following statements is false?
A. In the early postoperative period leaks are evaluated using water soluble contrast.
B. If water soluble contrast esophagogram is negative then patient must undergo high density barium esophagogram
C. the benefit of discovering a small leak outweighs the risk of mediastinitis caused by barium.
D. Risk of pulmonary edema is higher with iohexol as compared to diatrizoate
Ans D -
Risk of pulmonary edema after the aspiration of water soluble contrast material depends on the volume aspirated and the osmolarity of the material aspirated.
Aspiration of high osmolar water soluble contrast material such as diatrizoate meglumine, or diatrizoate sodium is more likely to cause pulmonary edema than aspiration of a similar amount of low-osmolar water soluble contrast material, such as Iohexol.
Shackleford 8e pg 73.
Smaller soft tissue pseudomass in fundus and angulation of the intra-abdominal esophagus is the post operative radiologic picture of which of the following?
A. Nissen Fundoplication
B. Belsey Mark IV repair
C. Hill
D. Toupet
Ans B -
Radiographically the Nissen Wrap creates a smooth symmetric fundal soft tissue pseudomass and the esophagus passes through the centre of this pseudomass.
Belsey mark IV procedure uses a 240 degree fundal wrap with suturing of the esophagus to the gastric fundus to recreate an acute angle of His. This results in a smaller soft tissue pseudomass in the fundus and angulation of the intra-abdominal esophagus.
During the Hill procedure the GEJ is sutured to the median arcuate ligament posteriorly. No fundoplication is performed. This procedure results in lengthening of the intra-abdominal esophagus and exaggeration of the angle of His.
Shackleford 8e Pg 74.
Most commonly used subsitute for the esophagus is ?
A. Stomach
B. colon
C. Jejunum
D. B and C
Ans A -
Stomach, colon and jejunum are used as esophageal subsitutes with gastric subsitution being the most common.
Shackleford 8e pg 74.
A patient who underwent esophageal resection, complaints of fever and pain in the chest on the second day after the surgery. What should be the next investigation.
A. Esophagogram with water soluble contrast.
B. Esophagogram with barium
C. Contrast Enhanced CT chest
D. Endoscopy
Ans A -
Pain and fever after esophagectomy warrant emergency esophagogram with water soluble contrast material, and if necessary barium.
Barium is usually used if the initial water soluble contrast is negative.
CT is a secondary investigation, it is used in patients which have been shown to have leak by esophagogram to assess for the presence of any collection, mediastinitis, etc.
Shackleford 8e Pg 74, 72.
which of the following is not a feature of Schatzki’s ring?
A. Diameter is usually less than 14mm
B. Idiopathic
C. associated with GERD
D. usually symptomatic
Ans C -
the term Schatzki’s ring should be reserved for stenotic mucosal rings measuring less than 14 mm in diameter. These are the rings associated with dysphagia and risk of food impaction. They are idiopathic and not thought to be causally related to reflux esophagitis. Occassionally, a ring like stricture secondary to chronic GERD may resemble a Schatzki ring. These strictures can usually be distinguished from a Schatzki ring by their more superior location relative to the GEJ, and their association with additional findings of chronic reflux esophagitis.
Note : Bailey 27th edition - there is strong association of Schatzki ring with GERD
Sabiston 20th edition - the association of schatzki ring with GERD is strongly debated.
Shackleford 8e Pg 77
Which of the following is not a feature associated with esophageal webs ?
A. Common in the cervical esophagus B. Usually U shaped C. Indent the posterior and lateral walls. D. measure 1-2mm in thickness E. asymptomatic.
Ans C -
Classic esophageal web occurs in the cervical esophagus just below the cricopharyngeal muscle. Unlike esophageal rings, cervical esophageal webs are not usually circumferential, rather they are U shaped and indent the anterior and lateral walls, but spare the posterior wall. Most of them measure 1-2 mm in thickness, do not narrow the esophageal lumen and are asymptomatic.
Shackleford 8e Pg 77
