Esophageal strictures

Question 1

Which esophageal stricture is caused by an idiopathic proximal loss of Auerbach’s plexus, which leads to increased LES pressure?

Answer 1

Achalasia

Question 2

Why is the loss of the Auerbach plexus a big deal?

Answer 2

The esophageal wall ganglion cells normally produce NO, leading to smooth muscle relaxation of the LES, without this inhibition, there is increased LES tone –> esophageal dilation

Question 3

What is the gold standard for diagnosing Achalasia?

Answer 3

Esophageal manometry-shows increased LES pressure >40mmHg

-decreased peristalsis

Question 4

A patients double-contrast esophagram reveals a “bird beak appearance of LES”. What is the most likely diagnosis?

Answer 4

Achalasia

Question 5

What is the management for Achalasia?

Answer 5

Decrease the LES pressure:

• Botulinum toxin injection lasts 6-12months
• Nitrates
• CCB
• pneumatic dilation of LES
• Esophagomyomectomy

Question 6

What is the management of Zenker’s diverticulum?

Answer 6

• Diverticulectomy

- Cricopharyngeal myotomy

Question 7

Which of the following is not true about Zenker’s Diverticulum?
A. It is a false diverticulum
B. It is a weakness at the junction between the cricopharyneas muscle and lower inferior constrictor
C. It involves the submucosa
D. It is diagnosed via Barium esophagram as a collection of dye behind the esophagus at the pharyngeal junction

Answer 7

C. It only involves the mucosa

Question 8

A patients esophagram reveals a “corkscrew” esophagus. What is the most likely diagnosis?

Answer 8

Diffuse Esophageal spasm

Question 9

What is the management of Boerhaave syndrome?

Answer 9

Small and stable: IV fluids, NPO, abx?, H2 blockers

Large and severe: Surgical repair

Question 10

What diagnostic study is used to definitively diagnose Boerhaave syndrome?

Answer 10

Contrast esophagram

Question 11

What PE finding is indicative of Boerhaave syndrome?

Answer 11

Crepitus on chest ausculation due to pneumomediastinum

Question 12

Which diagnostic test is preferred in diagnosing Boerhaave syndrome?

Answer 12

Gastrografin swallow

-Water soluble in case of perforation

Question 13

What is a Mallory-Weiss tear?

Answer 13

UGI bleeding from longitudinal mucosal lacerations at the GE junction or the gastric cardia

Question 14

What is the management of a Mallory-Weiss tear?

Answer 14

Supportive: most stop by themselves
-acid suppression helps healing

-Severe bleeding: 
epinephrine injection,
 sclerosing agent, 
band ligation, 
hemoclipping or balloon tamponade (Sengstaken-Blakemore tube or Minnesota tube)

Question 15

What is the diagnostic test of choice for an esophageal web or ring?

Answer 15

Barium esophagram (swallow)

Question 16

What is the management of a esophageal web or ring?

Answer 16

• Endoscopic dilation of the area if there is no reflux

- If reflux, do Anti-reflux surgery

Question 17

What is Plummer-Vinson Syndrome?

Answer 17

1. Dysphagia
2. Esophageal webs
3. Iron deficiency anemia

-Atrophic glossitis

Question 18

What is a Shatzki ring?

Answer 18

LOWER esophageal web/constrictions at the squamocolumnar junction

Question 19

Schatzi rings are associated with what kind of hernias?

Answer 19

Sliding hernias

Question 20

What are esophageal varices?

Answer 20

Dilation of the GE collateral submucosal veins as a complication of portal vein HTN

Question 21

What is the MCC of esophageal varices in children?

Answer 21

Portal vein thrombosis

Question 22

What is the MCC of esophageal varices in adults?

Answer 22

Cirrhosis

Question 23

What is the treatment of choice for an acute actively bleeding esophageal variix?

Answer 23

Endoscopic ligation

-Octreotide is pharmacological DOC

Question 24

Which abx are used as prophylaxis in esophageal varices?

Answer 24

1. Fluoroquinolones (Norfloxacin)
   OR
2. Ceftriaxone

Question 25

What is the TOC to prevent the rebleeding of esophageal varices?

Answer 25

Non-selective BB: Propanolol, Nadolol