Gastro-oesophageal reflux disease

Question 1

What is Gastro-oesophageal reflux disease (GORD)?

1 - stomach contents moving into oesophagus
2 - oesophagus contents moving into stomach
3 - stricture in oesophagus
4 - fistula in oesophagus

Answer 1

1 - stomach contents moving into oesophagus
- specifically acid which can damage the squamous cells of the oesophagus
- lower oesophageal sphincter becomes weak

• when it keeps happening this moves from reflux and becomes GORD and patients are symptomatic

Question 2

What is the key distinguishing feature between Gastro‑oesophageal reflux (GOR) and Gastro‑oesophageal reflux disease (GORD)?

1 - duration of symptoms
2 - if patients have reflux with symptoms or complications
3 - epithelial cells have become dysplastic
4 - patient smokes and has reflux

Answer 2

2 - if patients have reflux with symptoms or complications

Symptoms include: discomfort or pain severe enough to merit medical treatment,
GOR‑associated complications: oesophagitis or pulmonary aspiration).

Question 3

In Gastro‑oesophageal reflux, do patients always present with symptoms?

Answer 3

• No

Patients can be asymptomatic

Question 4

Gastro-oesophageal reflux is when patient present with reflux, but they are not symptomatic or do not require medical intervention. How common is this in paediatrics?

1 - 2%
2 - 20%
3 - 40%
4 - 80%

Answer 4

3 - 40%

Typically begin <8 weeks old and can occur >5/day, BUT reduces with time and most childreb by 1 years old are fine

Question 5

Gastro-oesophageal reflux is when patient present with reflux, but they are not symptomatic or do not require medical intervention. If a child presents with simple reflux, what intervention do they need?

1 - PPIs
2 - gaviscon
3 - no treatment needed
4 - trial different feeds

Answer 5

3 - no treatment needed

Need to reassure parents though, and the child needs to be gaining weight well

Question 6

Gastro-oesophageal reflux disease is when the stomach contents moving back into oesophagus chronically. How common is this in the western world in adults (those presenting with symptoms)?

1 - 2-3%
2 - 20-30%
3 - 40-50%
4 - >79%

Answer 6

2 - 20-30%

• likely to be higher but not everyone is symptomatic

Question 7

How long is the oesophagus generally?

1 - 2-5cm
2 - 12-15cm
3 - 25-27cm
4 - 35-40cm

Answer 7

3 - 25-27cm

Question 8

The oesophagus is generally 25-27cm long and can be divided into 3 main parts. Which of the following is NOT one of these parts?

1 - cervical
2 - thoracic
3 - aortic
4 - abdominal

Answer 8

4 - abdominal

Question 9

The whole digestive tract has multiple layers. Looking at layers of the small intestines, which layer does the oesophagus NOT have?

1 - mucosa
2 - submucosa
3 - muscularis propria (inner circular and outer longitudinal layer)
4 - serosa
5 - adventitia

Answer 9

4 - serosa

• surrounded by adventitia allows binding to surrounding tissues

Question 10

Which of the following is NOT a common cause GORD?

1 - lower oesphageal sphincter failure, repeat relaxation or inability to close fully
2 - NSAIDs
3 - diaphragmatic sphincter failure (hiatus hernia)
4 - increased intrabdominal pressure

Answer 10

2 - NSAIDs

Question 11

Gastro-oesophageal reflux disease (GORD) is when the stomach contents moving back into oesophagus chronically. What are the 2 most common risk factors for GORD?

1 - smoking
2 - Helicobacter pylori
3 - NSAIDs
4 - alcohol
5 - BMI
6 - hiatus hernia/repair on diaphragm
7 - prematurity
8 - neurodisability (cystic fibrosis)

Answer 11

2 - Helicobacter pylori
3 - NSAIDs

Question 12

Children, especially premature infants are at an increased risk of GORD. What is the main reason for this?

1 - lying down so much
2 - more acid in stomach than in adults that can damaged lower oesophageal sphincter
3 - lower oesophageal sphincter is immature and does not function as well as in adults
4 - no peristalsis in lower oesophageal

Answer 12

3 - lower oesophageal sphincter is immature and does not function as well as in adults

Lying down can also also contribute

Question 13

How does Helicobacter pylori cause Gastro-oesophageal reflux disease (GORD) and ulcers?

1 - secretes urease
2 - secretes protease
3 - secretes excessive pepsin
4 - secretes large volumes of CCK

Answer 13

1 - secretes urease

• urease converts urea into CO2 and ammonia
• ammonia neutralises parts of the stomach

Question 14

Helicobacter pylori cause Gastro-oesophageal reflux disease (GORD) and ulcers by secreting urease which converts urea into CO2 and ammonia neutralising parts of the stomach so it can survive. Where does H.pylori generally affect?

1 - fundus
2 - cardia
3 - antrum
4 - pyloris

Answer 14

3 - antrum

• lowest pH here so easier to survive

Question 15

In normal digestion, there is always a degree of acid reflux in most people, but what defence mechanism do we have that stops gastric acid moving up the oesophagus?

1 - oesophagus secretes HCO3-
2 - pyloric sphincter contracts
3 - diaphragm contracts
4 - secondary oesophageal peristalsis

Answer 15

4 - secondary oesophageal peristalsis
- moves gastric secretions back into stomach
- saliva secretions also help neutralise the acid pH

Lower oesophageal sphincter also contracts

Question 16

If gastric acid reflux becomes chronic, all of the following occur EXCEPT which one?

1 - metaplasia occurs (squamous to columnar)
2 - chronic inflammation causes oesophagitis
3 - fibrous scar tissue is deposited causing stricture of the oesophagus
4 - lower oesophageal sphincter ruptures

Answer 16

4 - lower oesophageal sphincter ruptures
- pathophysiology can lead to Schatski ring (narrow at the entry between the oesophagus and stomach)

Question 17

Which of the following is NOT a symptom of Gastro-oesophageal reflux disease (GORD)?

1 - pyrosis (heartburn) causing discomfort
2 - dysphagia
3 - peptic ulcer
4 - pleural aspiration
5 - regurgitation

Answer 17

3 - peptic ulcer

To be diagnosed as GORD the symptoms must be sufficiently severe enough to warrant medical attention

Question 18

Are the symptoms of Gastro-oesophageal reflux disease (GORD) worse when standing or lying down?

Answer 18

• lying down

Question 19

Gastro-oesophageal reflux disease (GORD) is when the stomach contents moving back into oesophagus chronically. We may see a number of things, which of the following is least common structural change as a sign of GORD?

1 - polpys
2 - oeosphagitis
3 - oesphageal stricture
4 - barrett’s oesophagus

Answer 19

1 - polpys

Question 20

Gastro-oesophageal reflux disease (GORD) is when the stomach contents moving back into oesophagus chronically. When looking for a cause of, which of the following is most likely that we will be able to visualise?

1 - hiatus hernia
2 - polyps
3 - malignancy
4 - stricture

Answer 20

1 - hiatus hernia

• need to exclude malignancy though

Question 21

What cell type lines the surface of the oesophagus?

1 - columnar epithelial cells
2 - transitional epithelial cells
3 - cuboidal epithelial cells
4 - squamous epithelial cells

Answer 21

4 - squamous epithelial cells

Question 22

Gastro-oesophageal reflux disease (GORD) is when the stomach contents moving back into oesophagus chronically and can cause Barrett’s oesophagus. What can we see at a cellular level in Barrett’s oesophagus?

1 - metaplasia
2 - dysplasia
3 - hypertrophy
4 - hyperplasia

Answer 22

1 - metaplasia (one cell type replaced by another)

• originally stratified squamous cells replaced by a single layer of columnar cells

Question 23

What is imaging modality can be used to diagnose and treat patients patients with gastro-oesophageal reflux disease (GORD)?

1 - barium swallow test
2 - pH and manometry test
3 - oesophagogastroduodenoscopy
4 - chest X-ray

Answer 23

3 - oesophagogastroduodenoscopy
- also known as an upper endoscopy

Biopsy may also be taken to diagnose oesophagitis and rule out other diagnoses

Question 24

What is a barium swallow test?

1 - contrast used as part of a CT scan
2 - contrast swallowed by patient
3 - contrast inject using an NG tube

Answer 24

2 - contrast swallowed by patient

• able to diagnose hiatus hernia and dysmotility
• not commonly performed anymore

Question 25

Which diagnostic technique is able to detect pH and the level of reflux that can be seen in gastro-oesophageal reflux disease (GORD)?

1 - barium swallow test
2 - CT contrast
3 - pH and manometry testing
4 - oesophagogastroduodenoscopy

Answer 25

3 - pH and manometry testing

• patient must have proven reflux with symptoms
• can also assess oesophageal function

In paediatrics this will typically be for 24h to quantify the degree of reflux

Question 26

In a child with gastro-oesophageal reflux, which of the following is NOT typically part of their management?

1 - Parental reassurance,
2 - Feeding assessment
3 - Smaller, more frequent feeds or
4 - Thickening agents to feeds (e.g.Gaviscon). A 1–2-week trial of alginate therapy, which forms a protective gel above stomach contents,
5 - small dose of PPIs

Answer 26

5 - small dose of PPIs

Question 27

In a child with gastro-oesophageal reflux, which of the following is NOT typically something that would make the doctors worry?

1 - Faltering growth from recurrent vomiting
2 - Reflux oesophagitis: haematemesis, discomfort on feeding or heartburn, iron-deficiency anaemia
3 - Recurrent aspiration- pneumonia, cough, wheeze, apnoea(Preterms)
4 - Frequent otitis media (e.g >3 episodes in 6 months)
5 - Conjunctivitis due to reflux
6 - Dental erosion
7 - Sandifer’s syndrome. Back arching

Answer 27

5 - Conjunctivitis due to reflux

This does not happen in gastro-oesophageal reflux

Question 28

In a child with gastro-oesophageal reflux disease (GORD), i.e. someone who has symptoms and requires medical management, would they typically be given thicker or thinner fluids to consume?

Answer 28

• thicker fluids

Question 29

In a child with gastro-oesophageal reflux disease (GORD), i.e. someone who has symptoms and requires medical management, can they be given PPIs?

Answer 29

• yes

Typically a H2 receptor antagonist such as omeprazole

Question 30

A fundoplication is an operation used to treat gastro-oesophageal reflux disease (GORD). Is this commonly used in children with GORD?

Answer 30

• Can be used, but is not common

Normally used in children with neurological conditions

Question 31

In a child with gastro-oesophageal reflux disease (GORD), i.e. someone who has symptoms and requires medical management, and they do not respond to common interventions, which of the following should be suspected?

1 - hirschsprung disease
2 - peptic ulcer
3 - non IgE mediated cow’s milk protein allergy
4 - coeliac disease

Answer 31

3 - non IgE mediated cow’s milk protein allergy

Especially in atopic patients

Question 32

In patients with gastro-oesophageal reflux disease (GORD), they may be treated conservatively and asked to modify their lifestyle first. Which of the following is NOT a lifestyle modification?

1 - weight loss
2 - smoking cessation
3 - alcohol cessation
4 - reduce fatty foods

Answer 32

4 - reduce fatty foods

• weight loss, but not specific to fatty foods

Question 33

In patients with gastro-oesophageal reflux disease (GORD), they may be treated conservatively. The first approach is lifestyle advice (smoking and alcohol cessation, weight loss). If this fails they may be prescribed what?

1 - analgesics
2 - proton pump inhibitors
3 - anticholinergics
4 - anti-histamine

Answer 33

2 - proton pump inhibitors

• Omeprazole or Lansoprazole
• also important to ensure H.pylori eradication

Question 34

If conservative management fails, surgery may be required. What surgery is most commonly performed?

1 - oesophagectomy
2 - total oesophagectomy
3 - fundoplication
4 - stenting

Answer 34

3 - fundoplication
- fundus of the stomach is partially or fully wrapped around the oesophagus

Question 35

Dysphagia is the medical term for difficulty swallowing. Dysphagia can occur at any stage of swallowing, which can be subdivided into 3 phases. Which of the following is not a phase of swallowing?

1 - oral
2 - pharyngeal
3 - larynx
4 - oeosphageal

Answer 35

3 - larynx

Question 36

Dysphagia is the medical term for difficulty swallowing. What is the most common cause of dysphagia?

1 - following cerebrovascular incident (stroke)
2 - peptic ulcer
3 - carcinoma of oeosphagus
4 -lymphadenopathy

Answer 36

1 - following cerebrovascular incident (stroke)

Question 37

A peptic ulcer is a common cause oeophagogastric dysphagia. How do peptic ulcers cause dysphagia?

1 - increased HCL can aspirate up oesophagus
2 - stricture formation
3 - atrophy of muscles

Answer 37

2 - stricture formation

• common in hiatus hernias

Question 38

Oropharyngeal candidiasis is an infection of the throat. What idiopathic cause is this common in?

1 - incorrect antibiotic use
2 - dental treatments
3 - following surgery
4 - exposure on a ward

Answer 38

3 - following surgery

Question 39

Myasthenia gravis occurs when the immune system makes antibodies that destroy the ACh receptor (AChR), a docking site for the nerve chemical acetylcholine (ACh). What can this cause in the oeosphagus?

1 - dysphagia
2 - hyper-peristalsis
3 - hypo-peristalsis
4 - adenocarcinoma

Answer 39

1 - dysphagia

Question 40

Patients with spastic disorders can have dysphagia of the oesophagus. One of these is called nutcracker/ jackhammer oesophagus. What happens here that causes dysphagia?

1 - very powerful peristalsis
2 - disjointed peristalsis
3 - lack of peristalsis and failure of LOS to relax
4 - very weak peristalsis

Answer 40

1 - very powerful peristalsis

Question 41

Which of the following are not common presentations of patients with nutcracker/jackhammer oesophagus?

1 - dysphagia
2 - hemoptysis
3 - chest pain

Answer 41

2 - haemoptysis

• generally diagnosed using manometry

Question 42

What are diffuse oesophageal spasms, which can cause dysphagia?

1 - very powerful peristalsis
2 - uncordinated peristalsis
3 - lack of peristalsis and failure of LOS to relax
4 - very weak peristalsis

Answer 42

2 - uncordinated peristalsis

• multiple parts of the oesophagus contract at once

Question 43

Oesophageal spasms, which can cause dysphagia are due to uncordinated peristalsis where multiple parts of the oesophagus contract at once. What is the incidence of this?

1 - 1 / 100,000
2 - 10 / 100,000
3 - 100 / 100,000
4 - 1000 / 100,000

Answer 43

1 - 1 / 100,000

Question 44

Achalasia can cause dysphagia. What is achalasia?

1 - genetic disorder causing strictures
2 - neurological disorder causing aperistalsis
3 - genetic disorder causing cachexia
4 - genetic disorder causing a laxity of the lower oesophageal sphincter

Answer 44

2 - neurological disorder causing aperistalsis
- essentially peristalsis if poor
- can be difficult to swallow solids and fluids
- myenteric nerve degeneration

Question 45

Achalasia is a neurological disorder where myenteric nerve degeneration occurs. This results in causing aperistalsis causing difficulty swallowing solids and fluids. In addition to dysphagia, the oesophagus can also dilate and enlarge. What is the cause of this?

1 - gastric acid irritate the oesophagus and cause dilation
2 - oesophagus dilates to accommodate food and drink
3 - lower oesophageal sphincter cannot relax so food and drink build up
4 - all of the above

Answer 45

3 - lower oesophageal sphincter cannot relax so food and drink build up
- looks like a birds beak on imaging

Question 46

Achalasia is neurological disorder causing poor peristalsis and therefore dysphagia. Primarily affects the lower oesophageal sphincter and smooth muscle of the oesophagus. What is the yearly incidence of achalasia?

1 - 1 / 100,000
2 - 10 / 100,000
3 - 100 / 100,000
4 - 1000 / 100,000

Answer 46

1 - 1 / 100,000

• very rare but increases with age
• lower oesophageal sphincter does not relax during swallowing

Question 47

Achalasia is neurological disorder causing poor peristalsis and therefore dysphagia. Does it affect men or women more?

Answer 47

• affects both equally

Question 48

What age group is most commonly affected by achalasia?

1 - 10-20 y/o
2 - 20-40 y/o
3 - 30-50 y/o
4 - >65 y/o

Answer 48

3 - 30-50 y/o

Question 49

When we are trying to diagnose achalasia, which one of the following is the first line?

1 - ultrasound
2 - MRI
3 - OesophagoGastroDuodenoscopy
4 - barium swallow with X-ray

Answer 49

3- OesophagoGastroDuodenoscopy
- typically use a combination of all of these

Question 50

Which of the following are NOT common presentations of a patient with achalasia?

1 - dysphagia (liquids and solids)
2 - chest pain
3 - distended abdomen
4 - reflux
5 - regurgitation
6 - weight loss

Answer 50

3 - distended abdomen

Question 51

A barium swallow with X-ray can be used to diagnose a patient with achalasia. What is the name given to the image that can often be viewed on an X-ray in a patient with a megaoesophagus due to achalasia?

1 - apple core
2 - coffee bean
3 - baby sign
4 - birds beak

Answer 51

4 - birds beak

Question 52

A high resolution oesophageal manometry is a test that measures pressure in the oesophagus (food pipe) and sphincters (ring like muscles at junction with stomach). What can this often show in a patient with achalasia?

1 - narrowing of lower oesophageal sphincter and lower pressure in oesophagus
2 - widening of lower oesophageal sphincter and lower pressure in oesophagus
3 - narrowing of lower oesophageal sphincter and increased pressure in oesophagus
4 - widening of lower oesophageal sphincter and increased pressure in oesophagus

Answer 52

3 - narrowing of lower oesophageal sphincter and increased pressure in oesophagus

Question 53

Which of the following is NOT a common treatment for achalasia?

1 - balloon dilation
2 - botox injection
3 - endoscopic myotomy
4 - NSAIDs

Answer 53

4 - NSAIDs

• endoscopic myotomy = removal of muscle layer from proximal oesophagus and lower oesophageal sphincter to help food and fluids flow

Question 54

Patients with severe achalasia may undergo a procedure called Hellers cardiomyotomy, which involves division of the lower oesophageal sphincter. What is the success rate of relieving dhyspagia?

1 - 0.8%
2 - 8%
3 - 38%
4 - 80%

Answer 54

4 - 80%

• BUT can increase risk of oesophageal perforation and cause contents to leak into mediastinum

Question 55

What scoring system is typically used to score manometric findings?

1 - CURB score
2 - Chicago classification
3 - Freemantle classification
4 - Modified Glasgow score

Answer 55

2 - Chicago classification

Question 56

In a patient that is having problems with both solids and fluids when swallowing, is this likely to be due to a functional or mechanical disorder?

• functional = muscles and nerves affecting motility of the esophagus
• mechanical = something within the esophagus blocking it

Answer 56

• functional = muscles and nerves affecting motility of the esophagus

Question 57

In a patient that is having problems with just solids when swallowing, is this likely to be due to a functional or mechanical disorder?

• functional = muscles and nerves affecting motility of the oesophagus
• mechanical = something within the oesophagus blocking it

Answer 57

• mechanical = something within the oesophagus blocking it
• such as adenocarcinoma or strictures

Question 58

In a patient that is having dysphagia, it can be intermittent or progressive. Of functional and mechanical, which will most commonly be intermittent and which progressive?

Answer 58

• intermittent = functional as swallowing is sometimes ok
• progressive = mechanical as something is growing or becoming narrower

Question 59

Look at the question in the image, what is the diagnosis:

Answer 59

• oesphageal cancer

Question 60

During the post take ward round the consultant asks you for the most common cause worldwide of GI bleeding. Which one of the following is the correct answer?

1. Oesophageal varices
2. GI tumours
3. Peptic ulcer disease
4. Dieulafoy lesions
5. Mallory Weiss tear

Answer 60

3. Peptic ulcer disease