Esophagus and Stomach - Shelf-Life Flashcards
A septuagenarian man receiving palliative care in an extended care
facility begins to develop recurrent pneumonias. A barium swallow
study is completed and reveals an obvious outpouching within the left
neck between the levels of the pharynx and the esophagus.
Which of the following is the most likely diagnosis?
(A) Meckel diverticulum
(B) Traction mid-esophageal diverticulum
(C) True diverticulum
(D) Zenker diverticulum
The answer is D: Zenker diverticulum . A Zenker diverticulum is an outpouching that occurs at the junction of the pharynx and esophagus, usually seen in the elderly, and typically first noticed secondary to dysphagia. The imaging study shows that the diverticulum is in the proximal esophagus.
Though aspiration resulting in pneumonia is infrequent, it can occur. It is easily
diagnosed with a barium study. Given the weakness of the diverticulum,
endoscopic approaches are avoided.
(A) A Meckel diverticulum (also a true diverticulum) typically presents
in childhood or presents as a bowel obstruction in adults.
(B) Mid-esophageal traction diverticulum is a true diverticulum that can be asymptomatic or present with dysphagia that has a different location than that described.
(C) A Zenker diverticulum is a pulsion (or false) diverticulum and therefore
not a true diverticulum (as is mid-esophageal diverticulum) .
A 42 -year-old man with longstanding alcoholism i s brought t o the
emergency department by his family after vomiting large volumes of
bright red blood. B edside esophagoscopy reveals tearing of the mucosa
near the gastroesophageal junction ( G E J). Which of the following statements
regarding this condition is true?
(A) Diagnosis cannot be established without the use of computed
tomography ( CT) scanning
(B) Endoscopy is not only diagnostic but also therapeutic
(C) The disease is usually fatal
(D) The morbidity of this disease typically necessitates surgical intervention
(E) The presentation of this disease is an indication to screen for Helicobacter
pylori
The answer is B : Endoscopy is not only diagnostic but also therapeutic. Mallory-Weiss syndrome is due to mucosal bleeding near the GEJ,
typically due to retching and often seen in patients with alcoholism (or severe
vomiting) . The disease course is fairly benign. This condition can be both diagnosed and treated endoscopically. Endoscopic treatment is typically successful with balloon tamponade, sclerotherapy, banding, hemoclipping, electrocoagulation, or heater probe application.
(A) A CT scan would contribute little to this clinical picture.
(C) Fatality due to Mallory-Weiss syndrome is very rare.
(D) Surgical intervention, which involved ligation, is required only for rare cases that fail endoscopic management.
A 50-year-old man presents to the emergency department following
the sudden onset of constant back and abdominal pain following prolonged
vomiting over the past few days. He denies hematemesis. Physical
examination of the oral cavity is unremarkable, but palpation of the chest
reveals crepitus, and auscultation reveals crunching sounds with individual
respirations. Which of the following is the best first step in diagnosis?
(A) CT scan
(B) CT scan with intravenous contrast
(C) Esophagoscopy
(D) Oral contrast study with barium
(E) Oral contrast study with Gastrografin
The answer is E: Oral contrast study with Gastrografin . The physical
examination findings described in this clinical vignette, specifically subcutaneous emphysema and palpable air in the mediastinum (so-called Hamman crunch), are classic for Boerhaave syndrome. Note the similar history to the Mallory-Weiss syndrome described above. In contrast to Mallory-Weiss syndrome, Boerhaave syndrome typically involved full-thickness tears of the
esophagus whose bleeding resolves spontaneously.
While the most common cause of Boerhaave syndrome is iatrogenic secondary to upper endoscopy, it can occur due to similar causes of Mallory-Weiss syndrome (trauma, heaving, retching, etc) . The gold standard for diagnosis of Boerhaave syndrome is an oral contrast study with water-soluble contrast (e.g., Gastrografin) .
(A) While C T can be effective in diagnosing esophageal rupture, the
low cost and high sensitivity of a water-soluble contrast study make CT a less
ideal choice of study.
(B) Not only would CT be less ideal for reasons stated above, but also the use of contrast would contribute little to this scenario.
(C) Upper endoscopy can be effective in determining the extent of damage,
but air introduced into the esophagus can worsen the patient’s condition.
(D) Barium should be avoided due to complications involving extravasation
into the mediastinum.
A 22-year-old woman is brought by rescue squad to the emergency
department following a failed suicide attempt. You are told on arrival that
she consumed a copious amount of an unidentified household cleaner
and was found covered with vomitus. She is febrile with otherwise normal
vitals, writhing in pain on her stretcher, and unable to provide any information.
Oral examination reveals erythema and hypersalivation. Which
of the following is the most crucial step in treatment of this patient?
(A) Administration of an emetic
(B) Encouragement of oral hydration
(C) Esophagoscopy
(D) Surgical intervention with resection of involved esophageal portions
The answer is C: Esophagoscopy. Esophagoscopy should be performed
first to examine the entire lining of the esophagus and assess the damage done by the offending agent. Assessment of damage can help to determine the treatment plan as well.
(A) Antiemetics should also be avoided as vomiting can “twice-expose”
the esophageal lining and increase the likelihood for perforation of a weakened mucosal lining.
(B) Oral hydration can be dangerous in this situation, where the substance is not identified, and water could cause further damage if proper neutralizing agents (for acidic or alkaline agents) are not given.
(D) Surgical resection of damaged esophagus may be indicated for stenosis or fistulae, but only after thorough examination and diagnosis via esophagoscopy.
An 86-year-old woman post mastectomy returns to your clinic for
scheduled follow-up. On review of systems, you learn that she has had
an unintentional weight loss of 1 5 pounds and has developed acute
onset of dysphagia with occasional regurgitation. Further questioning
reveals that her dysphagia occurs with both solids and liquids, and
that her dysphagic pain is relieved with nitroglycerin that was given
to her by her cardiologist. Her pain is not related to physical exertion.
Physical findings, including a thorough cardiovascular examination,
are normal.
Which of the following is the most likely diagnosis?
(A) Achalasia
(B) Gastroesophageal reflux disorder (GERD)
(C) Stable angina
(D) Type I hiatal hernia
(E) Zenker diverticulum
The answer is A: Achalasia. The symptoms described in this vignette are
classic for those of achalasia, where an aperistaltic esophagus and unrelaxed
lower esophageal sphincter lead to patient complaints. Dysphagia to solids
and liquids, regurgitation, and weight loss secondary to bothersome meals are classic findings. The relief of pain by nitroglycerin is due to the drug’s effect on sphincter tone (and can also be a finding in diffuse esophageal spasm). Physical examination is typically normal. The esophagogram shown reveals the infamous “bird’s beak deformity:’
(B) Though symptoms of GERD could be similar to those described
here (dysphagia, regurgitation) , this discomfort would not be relieved by nitroglycerin and not be so acute.
(C) While a cardiovascular workup is definitely indicated, this chest pain would not be diagnosed as “stable” angina given it lacks relation to physical exertion.
(D) Most type I hiatal hernias are asymptomatic unless they lead to GERD symptomatology.
(E) Finally, Zenker diverticula are typically asymptomatic unless progressive where they are associated with dysphagia that is localized cervically.
A 27 -year-old man presents to your clinic with postprandial retrosternal
burning and nausea. His symptoms occur nightly, are worse after
large meals, and commonly occur when he lies recumbent following
dinner. He has never sought treatment for this apparently new problem.
He has a benign past medical and surgical history. His family history is
noncontributory. He consumes two to three cups of coffee per day and
drinks an occasional beer (one to two per week) with dinner. Which of
the following is the best means to establish this patient’s diagnosis?
(A) Electrocardiogram
(B) Esophagogastroduodenoscopy (EGD)
(C) Oral contrast study with barium
(D) Trial of therapy with sublingual nitroglycerin
(E) Twenty-four-hour pH monitoring of the esophagus
The answer is E: Twenty-fou r-hour pH monitori n g of the esophag us.
The young gentleman in this question is presenting with the classic symptoms
of GERD, and the diagnosis is fairly straightforward. The question redirects,
however, to ask means of diagnosis (a redirect commonly used on USMLE
examinations ) .
The gold standard for diagnosing GERD is a 24-hour esophageal
pH monitor, where a pH less than 4.0 for 1 .3 % of the day (proximal
esophagus) or 4.2% of the day (distal esophagus) is sufficient for a diagnosis.
(A) An electrocardiogram (EKG) would be useful to diagnose angina
when it is present (or at least induced with an exercise or pharmacologic stress test).
(B) An EGD would be useful for GERD refractory to treatment, or as a
means to assess longstanding GERD complications (i.e., Barrett esophagus)
(C) A barium swallow study would b e useful in cases o f GERD attributable
to another cause (e.g., hiatal hernia)
(D) Finally, while a therapeutic trial is useful for GERD in the primary care setting (and typically the USMLE answer of choice given the cost-effectiveness) , an inappropriate medication is listed in this answer.
The patient in the previous question stem returns to your clinic following
the outpatient diagnostics you arranged. Which of the following
is the ideal management of this patient assuming that your suspected
diagnosis is confirmed?
(A) Endoscopic dilatation and/or stenting
(B) Nissen total fundoplication
(C) Pharmacologic therapy with ranitidine
(D) Pharmacologic therapy with omeprazole
(E) Watchful waiting
The answer is D : Pharmacologic therapy with omeprazole. We are
told that the patient from the previous question returns with a positive diagnosis for presumptive GERD, and we are asked the ideal treatment for this disease. In addition to conservative measures (avoidance of caffeine, alcohol and smoking, elevating the head of the bed, etc.), medications are the mainstay of treatment. While H2-receptor blockers (e.g., ranitidine) are effective for occasional GERD symptoms, we are told that this patient experiences nightly symptoms.
(A) Endoscopic dilatation would be appropriate if other pathology was
reported (achalasia, advanced cancer with compromised function, Schatzki ring, etc.) but there is no indication for this invasive procedure.
(B) A Nissen fundoplication is very effective in correcting and reversing pathology involved with symptomatic hiatal hernias, but again, nothing indicates the presence of such pathology.
(C) Proton pump inhibitors (PPis, e.g., omeprazole) are recommended for daily symptoms and have become the first-line drug for patients with GERD.
(E) Finally, watchful waiting is not appropriate given a confirmed diagnosis of GERD, as complications include Barrett esophagus, a disease state that predisposes to esophageal cancer (specifically esophageal adenocarcinoma) .
A 6 1 -year-old Caucasian man has decided to transfer the care of his
esophageal cancer to your facility. Records indicate that this patient was
diagnosed with esophageal adenocarcinoma based on numerous biopsies
collected during EGD 3 weeks prior. He indicates to you that he has an
extensive GERD history that he self-treated with occasional, over-thecounter
antacids for years. An extensive physical examination reveals
lymphadenopathy in his right supraclavicular region. Three nodes measure
greater than 2 em. They are fixed, matted, and hard upon palpation.
Which is the most accurate stage of this man’s disease based on the tumor,
nodes and metastasis (TNM) (AJCC) classification system?
(A) Stage I
(B) Stage II
(C) Stage III
(D) Stage IV
(E) Stage V
The answer is D : Stage IV. This is the classic patient for an esophageal cancer (a Caucasian man in his sixth to seventh decade) . He also indicates the classic history for esophageal adenocarcinoma, that is, longstanding, poorly treated GERD. Based on AJCC’s TNM staging system, metastatic esophageal cancer in general (adenocarcinoma or squamous cell carcinoma) is noted by the presence of distant organ or nodal involvement (M 1 b) or nodal involvement of the celiac of supraclavicular lymph nodes (M i a) . Typically, metastatic disease (M l or greater) is classified at stage IV disease, which this gentleman unfortunately has. Note that right-sided supraclavicular lymphadenopathy is more associated with esophageal cancers. This patient will likely proceed to palliative chemotherapy, radiation, or combination therapy.
(A) Stage I esophageal cancer lacks nodal involvement and is reserved
for T l disease.
(B) Stage II includes T3 disease without nodal disease, or T2 disease with nodes.
(C) Stage III is diagnosed in the presence of T4 disease
(cancer beyond the adventitia into adj acent structures) or for T3 disease (into
the adventitia only) with nodal involvement.
(E) There is no stage V based on the AJCC classification system.
A 47-year-old woman returns to your office following upper endoscopy
secondary to longstanding, refractory GERD. A review of the operative
report indicates that red, velvety patches of esophageal mucosa were
noted at the level of the GEJ. Multiple biopsies were taken. Review of
the corresponding pathology report indicates the presence of Barrett
esophagus. You communicate to the patient her increased risk for
esophageal malignancy and the need for continued medical, possible
surgical, therapy. Which of the following statements most accurately
describes the pathological findings in Barrett esophagus?
(A) Abnormal squamous maturation with numerous intraepithelial
eosinophils
(B) Invasion of dysplastic glandular cells into the lamina propria
(C) Metaplasia from a columnar epithelium to a squamous epithelium
(D) Metaplasia from a squamous epithelium to a columnar epithelium
(E) Multinucleated giant endothelial cells with cystoplasmic inclusion
bodies
The answer is D: Metaplasia from a squamous epithe l i u m to a col u m nar
epithel i u m . This patient undergoes appropriate endoscopic evaluation for
her longstanding refractory GERD symptoms. Endoscopic evaluation reveals
the classic gross description of Barrett esophagus (red, velvety changes near the GEJ) and pathology indicates as such. Barrett esophagus describes metaplasia (cell morphology change) from the native squamous epithelium of the distal esophagus to a columnar lining similar to that of gastric mucosa. Recall that Barrett esophagus predisposes to esophageal adenocarcinoma (not squamous cell carcinoma) .
(A) The presence of eosinophilic infiltrates does not describe Barrett
esophagus but indicates eosinophilic esophagitis, which can be present with
GERD.
(B) Note that an invasion of dysplastic cells into the lamina propria is by
definition invasive disease (i.e., cancer) and not a predisposing lesion such as
B arrett esophagus.
(C) The change of Barrett esophagus occurs with squamous to columnar metaplasia, not columnar to squamous metaplasia.
(E) Finally, multinucleated cells with cellular inclusions are classic for HSV or CMV infection; in this case, viral esophagitis in a likely immunocompromised patient.
A 39-year-old man is being followed up by you and your surgical colleagues
for longstanding GERD and a suspected hiatal hernia. His
symptoms include dysphagia and postprandial fullness. He has been
taking omeprazole for 6 months without alleviation of symptoms. No
endoscopic diagnostics have been attempted. Results from his video
barium esophagram reveal a stable GEJ with herniation of the stomach
beyond the diaphragm. Which of the following is the most likely
current working diagnosis?
(A) Type I (sliding) hiatal hernia
(B) Type II (paraesophageal) hiatal hernia
(C) Type III (mixed) hiatal hernia
(D) Type IV (mixed with other organ involvement) hiatal hernia
The answer is B: Type II (paraesophageal) hiatal hern ia. This patient
undergoes a barium esophagram study for a suspected hiatal hernia causing
his GERD symptoms. The description of a nonmobile GEJ with herniation
of the stomach into the thorax is the classic description of a paraesophageal
hernia (or a type II hiatal hernia) . Though paraesophageal hernias are rare,
surgical correction is needed to avoid herniation and strangulation.
(A) Note that type I hiatal hernias are typically asymptomatic. (C) By
definition, the GEJ is mobile in type III hiatal hernias. (D) In type IV (mixed)
hiatal hernia, the GEJ is also mobile.
A 56-year-old woman with longstanding history of alcohol-induced
end- stage liver disease (ESLD ) presents to the emergency department
with diffuse hematemesis. On admission, her systolic blood pressure
is 85 with an undetected diastolic. On examination, she has altered
mental status, an extensive amount of blood covering her clothing,
and dried blood over her oral mucosa. She appears jaundiced and
cachectic. A report from the emergency department physicians indicates
that she has vomited 750 cc of bright red blood since her arrival
30 minutes prior. Which of the following is the most appropriate next
step in management?
(A) A trial of medical management with continuous intravenous
octreotide
(B) Emergent surgery with creation of a portocaval shunt
(C) Endoscopic balloon tamponade
(D) Endoscopic band ligation of varices
(E) Transjugular intrahepatic portosystemic shunting (TIPS)
The answer is D: Endoscopic band ligation of varices. Here we have
a classic history for an esophageal variceal bleed: a patient with alcoholinduced cirrhosis who presents with hematemesis. Because mortality can be as high as 50% in initial variceal bleeds, and this woman is already exhibiting hypotension secondary to acute bloo d loss, this is an emergent situation. First-line therapy in actively bleeding esophageal varices is endoscopic hemorrhage control with band ligation or sclerotherapy given that effectiveness approaches 80 % .
(A) While octreotide and other somatostatin analogues are effective
pharmacologic agents, their efficacy is most evident when used in conjunction
with endoscopic management; therefore, medical treatment alone is
inappropriate.
(B) Surgical creation of shunts that decrease portal venous hypertension (e.g., portocaval) has mostly been replaced by the less invasive
TIPS procedure.
(C) Endoscopic balloon tamponade is far from first-line therapy, and is recommended when endoscopic, pharmacologic, and transjugular
therapies are not available.
(E) Finally, while TIPS is effective, it is best suited for patients that continue to hemorrhage following attempted endoscopic ligation with octreotide.
A 39-year-old woman presents to her primary care physician for heart
burn. She has a medical history of rheumatoid arthritis and systemic
lupus erythematosus (SLE ) , both of which are currently being treated
by her rheumatologist. She reports to you that she is ANA positive.
Prior to conducting your physical examination, which of the following
findings would you expect to find in this patient?
(A) Absence of ganglion cells on rectal biopsy
(B) Bird’s beak narrowing on esophagram
(C) Positive antimitochondrial antibodies
(D) Sclerodactyly
The answer is D : Sclerodactyly. Patients with a history of autoimmune
disease (e.g., rheumatoid arthritis, lupus) verified with positive serology
(antinuclear antibo dy (ANA) titers) with esophageal symptoms suggestive of
a dysmotility disorder should be evaluated for CREST syndrome (calcinosis
cutis, Raynaud phenomenon, Esophageal dysmotility, sclerodactyly, telangiectasia)
.
CREST syndrome, or scleroderma in general, causes fibrotic changes
of the esophageal sphincter and leads to aperistalsis with resultant esophageal symptoms. Sclerodactyly is classically found in b oth disease states.
(A) Absence of ganglionic cells in the rectum is p athognomonic for
Hirschsprung disease, a GI malformation commonly diagno sed in children.
( B ) A bird’s beak narrowing on barium esophagram is the classic
finding for achalasia, which is p o ssible but less likely given the medical history.
(C) Finally, positive testing of antimitochondrial antibodies describ es
the serology associated with primary biliary cirrhosis which produces no
esophageal symptoms.
Your surgery service is consulted to 51 -year-old woman in the emergency
department who is a long-term p atient at a psychiatric institution.
She recently began complaining of the inability to tolerate
oral intake, and proj ectile vomiting associated with meals. CT of the
abdomen obtained in the emergency departments reveals immense
distention of the stomach, which is full of contents including hair.
Which of the following is the most appropriate intervention to be
executed by the surgical team?
(A) Gastrectomy
(B) Splenectomy
(C) Endoscopic therapy
Chapter 5 : Esop hagus and Stomac h 99
(D) Vagotomy and pyloroplasty
(E) Proton pump inhibitors and two antibiotic therapies for 3 weeks
The answer is C : Endoscopic therapy. A bezoar is an accumulation of
undigested gastric material; those that contain hair are referred to as “trichobezoars:’ Patients subj ect to trichobezoars include the pediatric population and residents of psychiatric institutions. Large bezoars can present with signs and symptoms of gastric outlet obstruction (as seen in this clinical vignette) . Most bezoars can be roughly debrided with the use o f an endoscope; however, some must be decompacted surgically.
(A) Gastrectomy is a drastic management option regardless of the cause,
and is the least likely correct answer here.
(B) Splenectomy is completed unrelated to the pathophysiology, and we have no reason to believe that the spleen is pathologic (i.e., trauma, hypotension, meningeal sepsis)
(D) Vagotomy and pyloroplasty are reserved for intractable cases of peptic ulcer disease (PUD ) .
( E ) Th e use o f a PPI and antibiotics would be the therapy o f choice for PUD
associated with H. pylori infection, which is not described in this patient.
A 63 -year-old woman presents with dull, aching epigastric discomfort
associated with nausea that occurs following meals for the past 1 1 months.
She has noted alleviation with over-the-counter calcium carbonate. Her
past medical history is significant for endometriosis and two cesarean
sections, most recently 28 years prior. Vitals and physical examination
are normal other than vague epigastric tenderness. Her stool guaiac test
is positive. Her colonoscopies, up to date, have all been normal. Which of
the following is the most appropriate next step in management?
(A) Acquisition of serum gastrin levels
(B) Drawing of serology for anti-H. pylori antibodies
(C) Diagnostic laparoscopy
(D) Medical management with omeprazole
(E) Esophagogastroduodenoscopy
The answer is E: Esophagogastrod u odenoscopy. The gold standard in
diagnosis of peptic ulcer disease (PUD ) , which is fairly straightforward given
this patient’s history and physical examination, is upper endoscopy. Upper
endoscopy helps to differentiate stomach cancer and PUD, which prevent with similar symptoms along with gastrointestinal bleeding. Endoscopy allows biopsying of active ulcers to rule out malignancy and determine the involvement of H. pylori (commonly causative of PUD) with the Campylobacter-like organism CLO test. The hallmark of PUD management, therefore, is upper endoscopy.
(A) Assessing serum gastrin levels can be diagnostic of Zollinger-Ellison
(ZE) syndrome, which typically presents as refractory PUD with severe, nonhealing ulcers.
(B) Assessing serology for H. pylori infection is an effective means to determine need for triple therapy, but since endoscopy should be
performed, these data will be collected elsewhere.
(C) Diagnostic laparoscopy would determine the extent of this patient’s endometriosis, which is a distracter here given that her disease is clearly gastrointestinal-related.
(D) While medical management with omeprazole is likely to follow formal diagnosis, upper endoscopy should first rule out a more serious disease (e.g., gastric adenocarcinoma) before treating presumptive PUD.
The patient in the previous question follows the management plan
you selected. Results following this management plan confirm your
suspected diagnosis, along with infection of H. pylori, the suspected
causative agent. Which of the following is the most appropriate current
treatment for this patient?
(A) Amoxicillin, clarithromycin, and omeprazole for 10 to 14 days
(B) Amoxicillin, clarithromycin, and omeprazole for 30 days
(C) Metronidazole, clarithromycin, and omeprazole for 30 days
(D) Metronidazole, tetracycline, and omeprazole with bismuth for
1 0 to 1 4 days
(E) Metronidazole, tetracycline, and omeprazole with bismuth for
30 days
The answer is A : Amoxicillin , clarithromycin , and omeprazole for
1 0 to 14 days. This question asks for the recommended therapy for eradication of H. pylori.
This patient with diagnosed peptic ulcer disease (PUD) is confirmed to have H. pylori infection, a very common occurrence, and should therefore proceed to triple therapy of a PPI and two antibiotics (commonly amoxicillin and clarithromycin) .
Note that all of the answer choices are viable treatment options, but are not first line.
(B) The typical recommended duration of the medication is 10 to 14 days,
but not as long as 30 days, which would be excessive.
(C) Replacing amoxicillin with metronidazole is done for patients with a penicillin allergy, but we are not told this allergy exists.
(D) Quadruple therapy with bismuth, a PPI, metronidazole, and tetracycline is reserved for H. pylori strains resistant to the first -line triple therapy.
(E) Quadruple therapy is also effective if given for 10 to 14 days, and 30 days of treatment is unnecessary.
