Diagnostic evaluation of the eosphagus Flashcards
1
Q
The most common cause for failure of anti-reflux surgery?
A. Poor surgical Technique
B. Poor compliance
C. Poor Patient selection
D. idiopathic
A
Ans C - the most common cause of failure after antireflux surgery is poor patient selection.
Shackleford 8e Pg 44.
2
Q
Most common presenting complaint of esophageal cancer?
A. Hematemesis
B. Dysphagia
C. Weight Loss
D. Bloating
A
Ans B - dysphagia is the most common presenting symptom associated with esophageal cancer
Shackleford 8e Pg 44.
3
Q
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.
A
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.
4
Q
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
A
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.
5
Q
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.
A
Ans A - Acid infusion in the esophagus is tested using the bernstein test.
Shackleford 8e Pg 44.
6
Q
which of the following is not an atypical symptom of GERD?
A. Dental Caries
B. Globus sensation
C. Dysphagia
D. Noncardiac Chest pain
A
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.
7
Q
most common esophageal symptom of GERD ?
A. Regurgitation
B. Heartburn
C. Dysphagia
D. Burning sensation in epigastrium
A
Ans B - Heartburn is the most common esophageal symptom of GERD.
Shackleford 8e Pg 45.
8
Q
what percentage of western population experiences weekly symptoms of heartburn?
A. 10-20%
B. 20-30%
C. 40-50%
D. 60%
A
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.
9
Q
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
A
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.
10
Q
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.
A
Ans C -
Anti-reflux surgery should not considered a viable option for the treatment of globus sensation alone.
Shackleford 8e Pg 48.
11
Q
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
A
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.
12
Q
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
A
Ans D - Chronic cough.
Shackleford 8e pg 49,50.
13
Q
what is the duration of the refractory period of the esophagus?
A. 10s
B. 20s
C. 30s
D. 40s
A
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.
14
Q
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
A
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.
15
Q
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
A
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.
16
Q
which of the following is not mandatory during a work up of Paraesophageal hernias?
A. pH studies
B. Barium studies
C. Endoscopy
D. Manometry
A
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.
17
Q
Cameron ulcers are typically related to ?
A. Burns
B. Head injury
C. Hiatal hernia
D. both B and C
A
Ans C - hiatal hernia.
Shackleford 8e Pg 52.
18
Q
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
A
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.
19
Q
First investigation in evaluation of dysphagia?
A. Barium Esophagogram
B. Endoscopy
C. Manometry
D. pH studies
A
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.
20
Q
which part of the esophagus has the lowest normal contractile amplitude?
A. Cricopharyngeal
B. Proximal thoracic
C. Middle thoracic
D. Distal thoracic
A
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.
21
Q
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
A
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
22
Q
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
A
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.
23
Q
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
A
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
24
Q
Reticular mucosal pattern on esophagogram is typically said to be associated with
A. GERD
B. Hiatal hernia
C. Barrett’s esophagus
D. achalasia
A
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.
25
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.
26
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.
27
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.
28
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.
29
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.
30
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.
31
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.
32
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.
33
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.
34
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.
35
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.
36
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.
37
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.
38
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.
39
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.
40
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.
41
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.
42
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.
43
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.
44
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.
45
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
46
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
47
Which of the following is not a association of Paterson-Kelly syndrome ?
```
A. Cervical esophageal web
B. predisposition to hypopharyngeal/esophageal cancer
C. Iron deficiency
D. Splenomegaly
E. None of the above
```
Ans E - None of the above.
Plummer-Vinson syndrome or Paterson-Kelly syndrome is associated with A, B, C and D.
However the presence of cervical web in asymptomatic patients has called into question this classical association.
Shackleford 8e Pg 77, 78.
Bailey 27th edition -
Dysphagia is said to occur because of the presence of a postcricoid web that is associated with iron deficiency anemia, glossitis and koilonychia. The classic syndrome is rarely complete. Some patients may have oropharyngeal leukoplakia, and this may account for alleged increased risk of developing hypopharyngeal cancer.
Webs certainly occur in the upper and middle esophagus, usually without any kind of associated syndrome. They are nearly always thin diaphanous membranes indentified coincidentally on contrast studies. Even symptomatic webs that cause a degree of obstruction may be inadvertantly ruptured at endoscopy. Few require formal endoscopic dilation.
48
Esophageal webs may be associated with all of the following except ?
A. Cicatricial Pemphigoid
B. Iron deficiency anemia
C. Down Syndrome
D. Splenomegaly
Ans - C down syndrome
Cicatricial pemphigoid and epidermolysis bullosa occasionally involve the esophagus. Webs and strictures of various lengths are typical findings, usually more common in the upper esophagus. The associated skin lesions are the key to diagnosis.
Iron deficiency anemia and splenomegaly can both be present in paterson kelly syndrome.
Shackleford 8e Pg 77 and 78.
49
Which of the following is associated with corrugated appearance of strictures ?
A. Prolonged Nasogastric intubation
B. Eosinophillic esophagitis
C. Crohn's disease
D. Scleroderma
Ans B -
Prolonged nasogastric intubation results in long, smoothly tapered strictures in the mid and lower esophagus.
Radiation therapy produces smooth strictures of mid-esophagus.
Eosinophillic esophagitis strictures may involve the upper and mid esophagus. Some of these strictures have corrugated appearance, while others lead to diffuse and uniform narrowing of the esophagus.
Shackleford 8e Pg 79.
50
Threadlike appearance of strictures is associated with ?
A. Caustic ingestion
B. Eosinophillic esophagitis
C. Scleroderma
D. Radiation
Ans A - Caustic ingestion is associated with long irregular strictures of the midesophagus. There is a marked narrowing of the lumen producing a threadlike appearance.
Shackleford 8e Pg 79.
51
downhill varices are commonly seen in
A. Alcoholic liver disease
B. Extrahepatic Portal venous obstruction
C. Left sided portal hypertension
D. SVC obstruction
Ans D
The distal esophageal varices are often referred to as the uphill varices because of the inferior to superior direction of blood flow inside them.
Rarely varices may be demonstrated in the upper part of the esophagus, these varices represent venous shunts between the superior and inferior vena cava secondary to the obstruction of the superior vena cava and they are often refered to as downhill varices because of the direction of blood flow inside them.
Shackleford 8e Pg 82.
52
Esophagus is normally lined with
A. Pseudostratitified squamous epithelium
B. Stratified squamous epithelium
C. Keratinizing sqaumous epithelium
D. Simple squamous epithelium
Ans B -
The esophageal lumen is collapsed at rest and must be distended with air during endoscopy so that the stratified squamous epithelial lining can be visualised well.
Shackleford 8e Pg 85.
53
regarding congenital rests of heterotopic gastric mucosa all of following are true except -
A. present within the a few centimeters of the UES
B. Columnar epithelium with reddish and velvet like appearance.
C. Can be found in upto 11% of endoscopic examinations
D. Cannot produce acid and therefore of no clinical significance.
Ans D -
In the proximal esophagus within a few centimeters of UES, it is common to find patches of columnar epithelium that have a reddish and velvetlike texture similar to the epithelium of the stomach. These so called inlet patches are believed to be congenital rests of heterotopic gastric epithelium. If sought specifically they can be found in upto 11% of patients who have endoscopic examinations.
Inlet patches are usually of no clinical significance, but they can produce acid and in rare cases cause peptic ulcerations in proximal esophagus.
In addition they can occasionally contain intestinal metaplasia and rare instances of adenocarcinoma have been described.
Shackleford 8e Pg 85.
54
Aortic arch crosses the esophagus at -
A. 15 cm from incisors
B. 23 cm from incisors
C. 25 cm from incisors
D. 30 cm from incisors.
Ans B -
The esophagus is indented on its left side by the aortic arch. This pulsating indentation can be noted during endoscopic examination at a distance of approximately 23 cm from the incisor teeth.
Just below the arch at approximately 25cm, the left main bronchus causes a subtle indentation on the left anterior aspect.
The heart normally causes no prominent indentation, but atrial pulsations can often be visualised at a level approximately 30cm from the incisor teeth.
Shackleford 8e Pg 85.
55
Which of the following is not an endoscopic criteria for definition of GEJ ?
A. Level at which the tubular esophagus flares to become sac like stomach
B. Proximal margin of the gastric rugal folds.
C. the distal end of the esophageal palisade vessels.
D. Squamo-columnar junction
Ans D -
although A, B and C are considered the endoscopic criteria for defining GEJ
A - the location of point of flare changes with respiratory and peristaltic acitivity
B - the proximal gastric folds can prolapse transiently up into the esophagus.
C - palisade vessels can be difficult to identify using conventional endoscopy.
56
Vessels in the palisade zone of esophagus are located in which layer
A. Muscularis mucosae
B. Lamina propria
C. Muscularis propria
D. Adventitia
Ans - B
The palisade zone comprises a group of fine, longitudinal veins located largely within the lamina propria of the distal esophagus.
The palisade vessels pierce the muscularis mucosae distally to join the submucosal vessels of the perforating Zone and gastric zone.
Appearance of the palisade zone vessels can be enhanced by the narrow band imaging endoscopy using primarily blue light.
Shackleford 8e Pg 87
57
ZAP classification is used for -
A. Squamo columnar junction in esophagus.
B. Peptic ulcers.
C. Acute Pancreatitis
D. Primary sclerosing cholangitis
Ans A -
ZAP or Z line appearance classification has four categories.
Grade 0 - sharp and circular.
Grade I - irregular with tonguelike protrusions and/or islands of columnar epithelium
Grade II - distinct obvious tongue of columnar epithelium less than 3cm in length
Grade III - distinct tongue of columnar epithelium greater than 3cm in length or cephalad displacement of the entire Z line more than 3cm from the GEJ.
Higher grades of ZAP classification have a higher likelihood of harboring intestinal metaplasia. However the clinical utility of this classification is not established.
Shackleford 8e pg 88.
58
which of the following is most widely followed classification for Z line ?
A. Prague C and M classification
B. ZAP classification
C. Long segment and Short segment BE
D. none of the above,
Ans C -
Long segment defined arbitrarily as more than 3cm and short segment defined arbitrarily as less than 3cm from GEJ is the most widely used classification for BE. The classification has no clear implication.
Shackleford 8e Pg 88.
59
which of the following is used to identify intestinal type cells specifically during chromoendoscopy ?
A. Potassium iodide
B. Methylene Blue
C. Cresyl violet
D. Indigo Carmine
Ans B
Potassium iodide - absorbed by squamous epithelial cells and binds to their glycogen and stains them brown. Helps to delineate SCJ and identify areas of early neoplasm in squamous epithelium
Methylene Blue - absorbed by the intestinal type cells and therefore can be used to identify areas of intestinal metaplasia in a columnar lined esophagus.
In addition areas of dusplasia and early cancer in specialized intestinal metaplasia can be identified by their inability to absorb methylene blue.
One report - methylene blue can cause DNA damage in BE.
Indigo Carmine - not absorbed. Used to enhance architectural features.
Cresyl Violet - stains the columnar cells that absorb it purple. The dye also accumulates in the crevices to enhance architectural features.
Acetic Acid - sprayed on the mucosa before chromoendoscopy as a mucolytic agent. Also causes columnar epithelium to swell and may enhance evaluation of the architectural features.
Shackleford 8e Pg 89.
60
what is the maximum magnification afforded by magnification endoscopy ?
A. 10x
B. 20x
C. 50x
D. 150x
Ans D -
optical zoom device is used to magnify the mucosa upto 150x.
Magnification endoscopy can also be combined with chromoendoscopy.
Shackleford 8e Pg 89.
61
pit patterns seen on magnification endoscopy are suggestive of ?
A. Squamous epithelium
B. Columnar epithelium
C. Columnar epithelium with intestinal metaplasia
D. Columnar epithelium with intestinal metaplasia with dysplasia
Ans C -
pit patterns might be typical of intestinal metplasia of the BE.
Shackleford 8e Pg 89.
62
which of the following is not used to classify erosions on endoscopy ?
A. Savary Miller
B. Rockall
C. MUSE
D. Los Angeles
Ans B -
Savary Miller, MUSE and Los Angeles classification are all used to define reflux esophagitis on endoscopy.
Los Angeles is the most widely used of the three.
Shackleford 8e pg 90.
63
Circumferential erosions are classified as what grade in Savary Miller classification of Reflux esophagitis ?
A. Grade I
B. Grade II
C. Grade III
D. Grade IV
Ans C -
```
Grade 0 - normal mucosa.
Grade I - discrete areas of erythema
Grade II - non-circumferential erosions
Grade III - circumferential erosions
Grade IV - GERD complications - ulcers, strictures, BE
```
Shackleford 8e Pg 91.
64
A patient who complains of severe regurgitation and heartburn undergoes endoscopy and is found to have a stricture measuring 9mm in diameter. What is the Grade of reflux esophagitis as per MUSE classification ?
A. Grade 0
B. Grade I
C. Grade II
D. Grade III
Ans - C - grade II
MUSE stands for metaplasia, Ulcer, stricture and Erosion classification.
M0 - absent, M1 - one island of metaplasia, M2 - circumferential.
U0 - no ulcer, U1 - single ulcer, U2 - 2 or more than 2 ulcers.
S0 - no stricture, S1 - diameter more than 9mm, S2 diameter 9mm or less.
E0 - no erosion, E1 - single erosion, E2 - circumferential erosion.
Erosion - reaching into the mucosa, Ulcer - reaching upto the submucosa - needs Histological analysis.
Shackleford 8e Pg 91.
65
what grade represents severe reflux esophagitis as per Los Angeles classification ?
```
A. Grade A
B. Grade B
C. Grade C
D. Grade D
E. Both C and D
```
Ans E -
Grade C and D are considered severe reflux esophagitis as per Los Angeles classification.
Shackleford 8e pg 91.
66
which of the following is suggestive of a properly constructed fundal wrap on endoscopy ?
A. Presence of gastric rugal folds above the pinch of the fold.
B. Folds oriented parallel to the white distance line on the endoscope on retroflex view
C. absence of fundoplication folds.
D. thickness of folds 3-4cm
Ans B
presence of gastric folds above the pinch of the fundoplication is suggestive of a slipped Nissen.
Folds should be oriented parallel to the white distance line on the endoscope in retroflex. If they are obliquely oriented it suggests twisting of the fundoplication or improper construction of the wrap using the body rather than the fundus of the stomach.
The folds should measure approximately 1-2 cm in span. A wide span indicates a too generous fundoplication.
Shackleford 8e Pg 92.
67
Which of the following is not true regarding Eosinophillic esophagitis?
A. common in women
B. peaks in 4th and 5th decade.
C. long history of dysphagia for solid foods
D. personal and family history of food allergies and asthma, atopic dermatitis, hay fever.
Ans A -
EoE appears to be a manifestation of food allergy in which eosinophils infiltrate the esophageal epithelium.
Tissue damage mediated by cytokines released from eosinophils. Commonly diagnosed in men in the fourth and fifth decade of life who describe a long standing history of dysphagia for solid foods, often with hospital visits for food impaction.
Heartburn is also a common complaint, and it can be sometimes difficult to differentiate EoE from GERD.
Patients frequently have a personal and family history of allergic disorders, eczema, hay fever, and food allergies.
Children with EoE may have pain, heartburn, vomiting, feeding disorders and failure of thrive.
Shackleford 8e Pg 93.
68
which of the following is not true regarding eosinophillic esophagitis ?
A. Multiple esophageal rings are common endoscopic findings
B. trachea like appearance on endoscopy
C. Vertical furrows, strictures, white specks of 1-2mm and small caliber esophagus
D. Endoscopy is diagnostic
Ans D -
Multiple esophageal rings are common endoscopic findings in patients with EoE. When pronounced the rings may give the esophagus a trachea like appearance.
Other common endoscopic abnormalities are vertical furrows, strictures, white specks of 1-3mm diameter eosinophilic exudates.
in upto 25% cases the esophagus appears normal.
Esophageal biopsy is needed to establish the diagnosis.
The esophageal mucosa is fragile and esophageal dilations often are complicated by extensive mucosal tears that can be quite painful.
Shackleford 8e Pg 94.
69
which of the following is the best for transmission of ultrasonic waves used in USG ?
A. Air
B. Soft tissue
C. Bone
D. Both B and C
Ans B -
In tissue with similar acoustic impedance, most of the wave is transmitted.
Soft tissue has excellent transmission qualities; the density and velocity vary only by 12% and 14% among the different soft tissues. Because acoustic impedance is the product of velocity and density, the product of these small changes results in 22% difference in acoustic impedance between fat and muscle.
Air is very compressible and of low density, whereas, bone although dense has low compressibility and high reflectivity. These properties account for poor transmission of ultrasound waves from tissue to air or tissue to bone.
Shackleford 8e Pg 95.
70
frame rate used by real time ultrasound ?
A. 10 fps
B. 12 fps
C. 8 fps
D. 4 fps
Ans B - 12 fps - the rate at which the eye cannot detect single images.
Shackleford 8e pg 96.
71
the frequency used in EUS ?
A. 5-10 MHz
B. 1-5 MHz
C. 5-20 MHz
D. 3-8 MHz
Ans - C -
Because the transducer is adjacent to tissues to be examined, higher frequencies than those used in extracorporeal ultrasound can be used. In the newest models, a range of transducer frequencies from 5-20 MHz are available. These transducers allow adequate visualisation of anatomic structures to a depth of 3-12cm.
Shackleford 8e Pg 96.
72
radial miniprobes used in EUS operate at a frequency of ?
A. 5-20 MHz
B. 7.5-12 MHz
C. 12-30 MHz
D. 15-22 MHz
Ans C - Radial mechanical blind probes having no endoscopic optical capabilities and less than 8 mm in diameter are used to evaluate esophageal strictures.
Higher frequency miniprobes passed through the operating channel of standard endoscopes provide radial images from 12-30 MHz.
Shackleford 8e Pg 96.
73
the third layer of the esophagus seen on EUS consits of?
A. Muscularis mucosae
B. Submucosa
C. interface between submucosa and muscularis propria
D. both B and C
And D -
First layer - Hyperechoic - Balloon mucosa interface.
Second Layer - Hypoechoic - Muscularis mucosae
Third layer - Hyperechoic - Submucosa and Submucosa-M. Propria interface.
Fourth Layer - Hypoechoic - muscularis propria without the submucosa-muscularis propria interface.
Fifth Layer - Hyperechoic - Peri-esophageal tissue.
For clinical purposes these layers repesent -
```
1st - Mucosa
2nd - Deep Mucosa
3rd - SubMucosa
4th - Muscularis propria
5th - periesophageal tissue
```
Shackleford 8e Pg 98.
74
Overdistension of the examining balloon or transducer if placed too close to the esophagus on EUS, it leads to -
A. Only two layers are visible
B. Only three layers are visible
C. Only four layers are visible
D. All 5 layer are visible
Ans B -
Only three layers remain visible as the mucosa, deep mucosa and submucosa become a single hyperechoic layer.
Shackleford 8e Pg 98.
75
Tumor location on endoscopy is best described as -
A. Distance from incisor to the proximal edge
B. distance from incisor to the distal edge
C. distance from incisor to the centre of the tumor
D. any of the above.
Ans A -
It is best expressed as distance from incisors to the proximal edge of the tumor.
Cervical tumor - between 15-20cm from incisor
Upper thoracic tumor - between 20-25cm from incisor
Middle thoracic tumor - between 25-30cm from incisor
Distal thoracic tumor - between 30-40cm from incisor.
Shackleford 8e Pg 101.
76
CT location of the tumor which has esophageal thickening that starts between azygous vein and inferior pulmonary vein
A. Cervical
B. Upper thoracic
C. Middle thoracic
D. Distal Thoracic
Ans C - middle thoracic.
Cervical tumor - thickening starts above the sternal notch.
Upper thoracic - thickening starts between sternal notch and the azygous vein.
Middle thoracic - thickening starts between azygous vein and inferior pulmonary vein.
Distal thoracic - thickening starts between the inferior pulmonary vein and diaphragm.
Shackleford 8e Pg 101
77
A cancer whose epicentre is 4 cm below the GEJ and extends into the esophagus is staged as -
A. Esophageal Cancer
B. Cardia cancer
C. Stomach Cancer
D. Either B or C
Ans A -
Cancers whose epicentre is in the lower thoracic esophagus, GEJ or within proximal 5cm of the stomach (Cardia) that extend into the GEJ or esophagus (Siewert III) are staged as adenocarcinoma of the esophagus.
All cancers with an epicenter in the stomach greater than 5cm distal to the GEJ, or those within 5cm of GEJ but not extending into it or the esophagus are staged using gastric cancer staging system.
Shackleford 8e Pg 101
78
Most accurate modality for clinical determination of depth of tumor invasion in esophageal cancer ?
A. CECT thorax
B. Endoscopy
C. EUS
D. Barium esophagogram
Ans C - EUS is the most accurate modality available for clinical determination of the depth of the tumor invasion.
In differentiation of T3 from T4 tumors, EUS is superior to CT.
Shackleford 8e Pg 102.
79
Most accurate for vascular involvement in esophageal cancers?
A. CT
B. EUS
C. Endoscopy
D. Barium
Ans B - EUS
When compared with CT, EUS provides a more sensitive and reliable determination of vascular involvement.
Shackleford 8e Pg 102.
80
Minimum Number of EUS that need to be performed before competence is obtained ?
A. 25
B. 50
C. 75
D. 100
Ans C - 75
75-100 examinations are required before competence is obtained.
Shackelford 8e Pg 102.
81
EUS has the highest accuracy for the diagnosis of which T stage ?
A. T1
B. T2
C. T3
D. T4
Ans D -
```
Variation in accuracy with T classification -
T1 75-82%
T2 64-85%
T3 89-94%
T4 - 88-100%
```
EUS is best used to differentiate T1/T2 tumors from T3/T4 tumors.
Shackleford 8e Pg 103.
82
The greatest inaccuracy of EUS is for which stage of esophageal cancer ?
A. T1
B. T2
C. T3
D. T4
Ans B - T2
The muscularis propria is vital in defining T1, T2 and T3 tumors. For clinical assessment the fourth layer seen in EUS is considered as muscularis propria. However this layer does not include the interface between submucosa and muscularis propria (it is located in third EUS layer).
Thus the border necessary to completely differentiate T1 from T2 tumors is contained in the 3rd ultrasound layer. As two boundaries must be assessed for determination of T2 and errors might occur at each, the inaccuracy is potentially twice that of T1 and T4 tumors.
Shackleford 8e Pg 103.
83
What tumor length is usually associated with a higher likelihood of T3 or higher tumors ?
A. 2cm
B. 5cm
C. 8cm
D. 10cm
Ans B - 5cm.
Tumor length greater than 5cm had a sensitivity of 89% and specificity of 92% for diagnosing T3 tumors.
Similarly presence of Luminal obstruction is also highly suggestive of a T3 or higher tumor.
Failure to pass an ultrasound probe beyond a malignant stricture is an accurate predictor of advanced stage. More than 90% of these patients will have a stage III or IV disease.
Careful dilation can be performed in such cases, however it is associated with a risk for perforation.
Use of miniature probes advanced through the stricture can accurately determine T classification in 85-90% cases, however they have limited depth of penetration and this may prevent full assessment. Because most non-traversable tumors are at least T3, it is crucial to evaluate the outer boundary of the tumor and adjacent structures and regional lymph nodes, which may be outside the range of the miniprobe.
As a rule of thumb if the tumor stricture is not allowing the passage of the EUS scope, the most practical option is to abort the procedure and manage the patient as atleast T3N1 and treat with neoadjuvant therapy.
Shackleford 8e Pg 104, 105.
84
which of the following is not an EUS criteria for diagnosis of metastatic lymph nodes?
A. Irregular border
B. Hypoechoic
C. Non-homogenous
D. Long axis more than 1cm.
Ans A -
Large (>1cm in long axis), round, hypoechoic, non-homogenous, sharply bordered lymph nodes are more likely to be malignant.
Small, oval or angular, hyperechoic homogenous lymph nodes with indistinct borders are more likely to be benign.
Shackleford 8e Pg 105.
85
Single most sensitive predictor in detecting N+ cancer on EUS
A. Sharp Border
B. Round shape
C. large size
D. Hypoechoic
Ans - D
the single most sensitive predictor in detecting N+ cancer was a hypoechoic internal echo pattern, followed by a sharp border, round shape and large size.
When all four factors are present the accuracy is 89-100%.
Also EUS is better in assessment of celiac lymph nodes (95% accuracy) than in mediastinal nodes (75%)
Shackleford 8e Pg 105.
86
which of the following is not true regarding EUS
A. EUS can accurately determine number of positive regional nodes and this clinical assessment is predictive of survival.
B. Close proximity of the regional node to the primary tumor is predictor of N+ cancer.
C. EUS FNA is more accurate than EUS alone for Nodal staging.
D. EUS-FNA is the most costly pathological staging strategy in patients with non-M1 esophageal cancer
Ans D
EUS detection of nodal metastases makes EUS-FNA the least costly pathologic staging strategy in patients with non-M1 esophageal cancer.
Shackleford 8e Pg 105.
87
Which of the following can be detected as a site of metastases in esophageal carcinoma by EUS ?
```
A. Low volume ascites
B. Left lateral segment of Liver
C. Celiac Lymph nodes
D. Retroperitoneum
E. All of the above.
```
Ans E -
EUS has limited value in screening for distant metastases. The distant organ must be in contact with the upper gastrointestinal tract for EUS to be useful. The left lateral segment of the liver and retroperitoneum are two such sites. EUS is capable of detecting low-volume ascites not apparent on CT.
This finding is associated with unresectable cancer in one half of patients with low volume ascites, and the remaining patients with low volume ascites, only half were able to undergo R0 resections.
Shackleford 8e Pg 106.
88
Which of the following is True statement regarding Esophageal carcinoma ?
A. Most common error in determining T classification in post-neoadjuvant setting with EUS is understaging.
B. Change in volume before and after chemoradiotherapy appears to be useful to assess response to therapy using EUS
C. EUS is better than CT in assessing response to neoadjuvant chemoradiotherapy
D. PET-CT is the preferred staging study after neoadjuvant therapy to exclude metastasis
Ans D.
A - Most common mistake made in determining T classification was overstaging because EUS is unable to distinguish tumor from inflammation and fibrosis.
B - Change in maximal cross-sectional area before and after chemoradiotherapy appears to be a more useful means of assessing the response. A response is defined as a 50% or greater reduction in tumor area.
C - EUS and CT have similar overall diagnostic accuracy for assessment of response.
Statement D is true.
Shackleford 8e Pg 106.
89
Which of the following is suggestive of malignant nature of lesions on EUS?
A. Anechoic
B. Homogenous echopattern
C. Size >4cm
D. Hyperechoic
Ans C
Homogenous lesions that are anechoic, of intermediate echogenicity or hyperechoic are almost exclusively benign.
A heterogenous echo pattern in lesions greater than 3-4cm in largest diameter, may be indicative of malignancy.
Shackleford 8e Pg 106.
90
Which of the following is true about fibrovascular polyps of esophagus ?
A. Arise from the muscularis mucosae
B. More common in the thoracic esophagus
C. Can cause sudden death by asphyxiation
D. Best diagnosed on EUS
Ans C -
A - Arise from the lamina propria. They are lined by normal squamous epithelium.
B - they most often arise from the cervical esophagus.
C. Most patients eventually complain of dysphagia and Respiratory symptoms. Spectacular manifestation include regurgitation into the hypopharynx and mouth with subsequent aspiration and occassionally sudden death from asphyxiation.
D - they are best detected on CT or Barium esophagography.
Definition by endoscopy or EUS may be difficult or impossible.
Shackleford 8e Pg 107
91
Which of the following is True about the Granular cell tumors?
A. 2nd most common benign esophageal tumor
B. Most common in ileum
C. most common in cervical esophagus
D. arise from Schwann Cells
Ans D -
A - they are the third most common benign esophageal tumor
B - esophagus is the most common gastrointestinal site
C - most commonly arise from the distal end of esophagus
D - arise from Schwann cells.
Shackleford 8e Pg 108
92
Which of the following is a true statement regarding Granular cell tumor ?
A. Most of them arise from the submucosa
B. No malignant variants
C. usually less than 2cm in daimeter with intermediate/hypoechoic solid pattern
D. Endoscopic biopsy is diagnostic in most cases.
Ans C -
A. Most of them arise from the mucosa. Only 5% arise from the submucosa.
B - Malignant variants are rare and distinguished by size >4cm, nuclear pleomorphism and mitotic activity.
C - EUS evaluation typically demonstrates tumors less than 2cm in diameter, intermediate or hypoechoic, mildly inhomogenous solid pattern with smooth borders and rising from the inner two EUS layers.
D. Endoscopic biopsy is diagnostic in only 50% patients.
Shackleford 8e Pg 108.
93
Which of the following is true regarding Esophageal lipomas ?
A. Firm to touch
B. Endoscopic biopsy is diagnostic
C. large lipomas require EUS followup
D. appear as homogenous hyperechoic lesions
Ans - D -
Soft texture when probed with esophagoscope.
Endoscopic biopsy usually produces normal overlying squamous epithelium because these sampling rarely penetrate the mucosa.
EUS demonstrates hyperechoic and homogenous lesion that originates in and is confined to the submucosal layer.
Most often found incidentally and require no EUS follow up.
Shackleford 8e Pg 109.
94
Most leiomyomas arise from ?
A. Lamina Propria
B. Muscularis Mucosae
C. Inner Circular muscle layer
D. Outer Longitudinal muscle layer
Ans B - EUS examinations reveal that majority of the esophageal leiomyomas are greater than 1cm in diameter and are most frequently found in the muscularis mucosae.
Shackleford 8e Pg 109.
95
Most symptomatic leiomyomas arise from ?
A. Lamina Propria
B. Muscularis Mucosae
C. Inner circular muscle layer
D. Outer Longitudinal muscle layer
Ans C
Symptomatic tumors arising from the muscular mucosae are rare, with the majority arising from the inner circular muscle layer in the distal and midthoracic esophagus.
Shackleford 8e Pg 109.
96
Which is the most common benign esophageal tumor ?
A. Lipomas
B. Neurofibromas
C. Granular cell tumors
D. Leiomyomas
Ans D - Leiomyomas are the most common benign esophageal tumors and account for >70% of all benign tumors.
Most common - Leiomyomas
2nd most common - esophageal cysts
3rd most common - granular cell tumors.
Shackleford 8e Pg 109
97
All of the following are true regarding esophageal leiomyomas except ?
A. Atypical EUS features are size >4cm, irregular margins, mixed internal echo, and associated regional LN.
B. Most commonly arise in the distal and midthoracic esophagus
C. No gender predisposition and peak in 20-50 years.
D. No EUS followup necessary in asymptomatic tumors
E. EUS FNA is usually not diagnostic.
Ans D -
Malignant transformation of benign leiomyomas has been infrequently reported. Surgical resection, by minimally invasive or endoscopic techniques if possible in symptomatic cases. In asymptomatic tumors with typical EUS features, expectant therapy plus EUS observation is indicated.
Shackleford 8e Pg 109.
98
which of the following is false regarding esophageal cysts ?
A. Majority are congenital
B. May contain smooth muscle, fat or cartilage
C. May be lined with respiratory epithelium
D. Trans-esophageal EUS drainage of the cysts is the treatment of choice.
Ans D -
Majority of esophageal cysts are congenital foregut cysts and minority are acquired epithelial cysts arising from lamina propria.
They are lined with squamous, respiratory or columnar epithelium.
Esophageal duplication is a subtype of esophageal cysts.
They are lined with squamous epithelium and have common submucosa and muscularis elements with the esophagus.
Trans-esophageal EUS drainage of the cysts has been reported but drainage without destroying the lining is associated with recurrence.
Shackleford 8e Pg 110.
99
Classic manometry uses
A. 4-5 sensors placed 6-8cm apart
B. 31 sensors placed 1cm apart.
C. 3-8 sensors placed 3-5cm apart.
D. Single sensor placed within 5cm of GEJ
Ans C -
Conventional manometry have characterized esophageal motor patterns with 3-8 pressure sensors placed 3-5cm apart, using pressure displayed along a time axis.
Shackleford 8e Pg 115
100
HRM uses -
A. 31 water perfused sensors placed 1 cm apart
B. 36 water perfused sensors placed 1cm apart
C. 36 solid state sensors placed 1cm apart
D. 40 solid state sensors placed 1cm apart.
Ans C - 36 solid state sensors placed 1cm apart.
Shackleford Pg 115.
101
What is the recording length of HRM ?
A. 30cm
B. 35cm
C. 36cm
D. 38cm
Ans B - 35 cm is the recording length of HRM. Spanning hypopharynx to stomach - with several intragastric sensors.
Shackleford 8e Pg 115.
102
Benefits of HRM over conventional manometry include all of the following except -
```
A. Standardized objective technique
B. Uniform high quality studies
C. Movement artefact reduced.
D. Interpretation is easier even for those not adept with conventional manometry.
E. All of the above.
```
Ans E - All of the above.
Shackleford 8e Pg 116.
103
All of the following requisites for HRM study except -
A. Supine position
B. 30s basal period without swallows
C. 10 swallows of 5mL each
D. Swallows separated by 10s
Ans D -
Test swallows are separated by at least 20s to re-establish basal activity and avoid having deglutitive inhibition.
Manometry is usually performed in supine position since this allows assessment of peristaltic function without the effect of gravity on bolus transit and esophageal contractile pressures.
However with solid state sensors although studies can be done in upright position, the currently available normative data is established in the supine position.
Shackleford 8e Pg 116.
104
EPT plots are also known as
A. Clouse Plots
B. Bell plots
C. Thomas Plots
D. Jeff Plots
Ans A - Clouse Plots.
Shackleford 8e Pg 116.
105
EPT plots the y axis represent
A. Time since last swallow
B. Length of the esophagus
C. Pressure over a segment of esophagus
D. None of the above
Ans B -
y axis represents the axial length of the esophageal body, with UES at the top and GEJ at the bottom.
x axis represents time.
whereas Pressure is represented by Color. Hot colors (Red, Orange) represent higher pressures, and Cool pressures represent green, blue pressures.
Shackleford 8e Pg 116.
106
the first step in the analysis of in HRM as per chicago classification?
A. UES pressure characterisation
B. Pan-esophageal pressure characterisation
C. EGJ pressure characterisation
D. Peristaltic pressure characterisation
Ans C -
A stepwise algorithm first characterizes EGJ pressure morphology and the adequacy of deglutitive inhibition.
Shackleford 8e Pg 117
107
Premature contraction is defined as a distal latency of ?
A. <4.5s
B. <4.1s
C. <5s
D. <5.5s
Ans A -
DL < 4.5s is defined as premature contraction.
Shackleford 8e Pg 117.
108
which of the following is not true regarding HRM ?
A. Significant breaks is peristalsis are common in the transition zone between striated and smooth muscle
B. Crural Diaphragm component of the EGJ pressure morphology is most prominent during expiration
C. GERD patients have significantly greater CD-LES separation
D. GERD patient tend to oscillate between the type I and type II EGJ conformation.
Ans B -
Significant breaks in peristalsis frequently occur in healthy individuals, especially at the transition zone in the proximal esophagus between striated and smooth muscle, and that these breaks are not a reliable measure.
The LES and CD contribute to the measured intraluminal EGJ pressure. The CD component is most evident during inspiration.
There are three types of EGJ morphology based on the distance between the LES and CD -
Type I - the LES is superimposed on the CD
Type II - the LES is 1-2cm superior to CD
Type III - the LES is more than 2cm separated to CD.
The GERD patients are found to have a significantly greater CD-LES separation, and also had significantly less inspiratory CD augmentation.
The GERD patients frequently oscillated between type I and Type II EGJ conformations and reflux events tend to occur preferentially during type II conformations.
Shackleford 8e Pg 118, 119.
109
Jackhammer esophagus is defined as -
A. 20% or more premature contractions with DL <4.5s
B. 20% of more contractions with DCI > 8000 mmHg.s.cm
C. IRP normal
D. Both B and C
Ans D - both B and C
Jackhammer esophagus is considered in patients who have a normal IRP and 20% or more contractions with DCI more than 8000 mmHg.s.cm
DES is considered in patients who have a normal IRP and 20% or more premature contractions with DL <4.5s with DCI > 450 mmHg.s.cm.
If DCI < 450 mmHg.s.cm with preamture contractions it fulfills criteria for failed peristalsis.
Shackleford 8e Pg 119.
110
Distal latency is defined as the duration of the interval between -
A. UES relaxation and LES relaxation
B. UES relaxation and CDP
C. UES relaxation and distal pressure trough
D. Any of the above
Ans B -
Distal latency in EPT terms is defined as the duration of the interval between UES relaxation and CDP.
Shackleford 8e Pg 121
111
All of the following are features of fragmented patterns on HRM Except -
A. Breaks >5cm in 20mmHg Isobaric pressure contour.
B. DL > 4.5s
C. DCI 450 mmHg.s.cm or more.
D. All of the above
Ans D -
Swallows with such large breaks >5cm are classified as having fragmented patter. These swallows must have normal DL (>4.5s) and DCI 450 mmHg.s.cm or more, or else they will be primarily classified as premature or ineffective.
Shackleford 8e Pg 122.
112
which of the following is considered an earlier form of classical achalasia ?
A. Type I
B. Type II
C. Type III
D. Both B and C
Ans B -
Although not definitely proven it is thought that type II likely represents an earlier presentation of the disease and these patients, if left untreated, will evolve into type I achalasia as the esophagus dilates and loses contractile ability.
Type III likely represents a separate disease entity.
Shackleford 8e Pg 122.
113
which of the following is true regarding the use of Botox in achalasia
A. Blocks the action of ACh on the post synaptic terminal, by irreversible blockade of the receptor.
B. Effect wears off by recruitment of new receptors.
C. botox can be used as a long term treatment option
D. mainly reserved for frail or elderly individuals who are poor risk
Ans D -
Blocks the release of ACh from the presynaptic terminals.
Effect wears off due to the growth of new axon terminals.
Although repeat treatments can be effective, average duration of effect of a single injection is 6 months and no data exist on botox as a long term treatment option
Studies comparing botox and pneumatic dilation suggest that the expense of repeated injections outweighs the potential economic benefits of added safety, unless the patient life expectancy is minimal.
Shackleford 8e Pg 123.
114
Therapeutic dilation for achalasia requires distension of the LES to a diameter of atleast
A. 10mm
B. 15mm
C. 20mm
D. 30 mm
Ans D -
therapeutic dilation for achalasia requires distension of the LES to a diameter of atleast 30mm to effect a lasting reduction of LES pressure, presumably by partial disruption of circular muscle fibers of the sphincter.
Failure of response with 30mm dilation can be retreated with 35 to 40mm diameters if needed.
Dilation with 60Fr Bougie or 2cm provide very temporary benefit at best and they are not considered defnitive treatment.
Success rate for pneumatic dilation is 70-90%.
Need for redilation is assessed at 4 weeks. Major complication is esophageal perforation with a rate of 0.4-5%.
Shackleford 8e Pg 123.
115
POEM may be better than laparoscopic Heller myotomy in -
A. Jackhammer Esophagus
B. Type II Achalasia
C. Type III Achalasia
D. Both A and C
Ans D -
POEM creates a 1-2cm mucosal incision in the distal esophagus and then a submucosal tunnel in the wall of the esophagus extending caudally.
Excellent outcomes have been reported upto 2 years with POEM comparable with Laparoscopic Heller Myotomy in terms of symptom relief and rate of GER.
POEM has the ability to perform a long myotomy that extends further cephalad than is possible with the laparoscopic approach. This could benefit patients with Type III and Jackhammer esophagus in which the hypercontractile segment extends to the transition zone in the proximal esophagus.
Shackleford 8e Pg 124.
116
which of the following is not a treatment option in patients with failed laparoscopic heller myotomy due to inadequate myotomy
```
A. POEM
B. Pneumatic Dilation
C. Repeat Heller Myotomy
D. Botox
E. Esophagectomy
```
Ans D - Botox.
Shackleford 8e Pg 124.
117
HRM definition of Nutcracker Esophagus is -
A. DCI >8000 mmHg.s.cm
B. DCI > 5000 mmHg.s.cm
C. DCI < 8000 mmHg.s.com
D. Both B and C combined
Ans D -
The conventional manometric defnition of hypertensive peristalsis used the term nutcracker esophagus and peak peristaltic amplitude of >180 mmHg between 3-8 cm above the LES.
More Recent work suggests that this should be increased to 260 mmHg, a value more likely to be associated with chest pain and dysphagia.
DCI Values of 5000 mmHg.s.cm is the 95th centile of normal. DCI values greater than 5000 mmHg.s.cm but less than 8000 mmHg.s.cm are found in inidividuals with hypertensive peristalsis akin to nutcracker esophagus in conventional terms.
In contrast DCI values >8000 mmHg.s.cm are almost universally associated with chest pain and dysphagia, and these patients appear to have a more exaggerated pattern of hypercontractility that is repetitive and more akin to a jackhammer than a nutcracker.
Shackleford 8e Pg 125.
