GERD/INFECTIOUS ESOPHAGITIS Flashcards
What is the primary cause of esophagitis in patients with gastroesophageal reflux disease (GERD)?
A) Direct caustic injury to the esophageal epithelium
B) Cytokine-mediated inflammatory pathway
C) Infection with Helicobacter pylori
D) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
Correct Answer: B) Cytokine-mediated inflammatory pathway
Rationale: Experimental evidence suggests that esophagitis in GERD patients is primarily caused by a cytokine-mediated inflammatory pathway, rather than direct caustic injury to the esophageal epithelium from refluxed gastric acid and pepsin.
Which of the following is the hallmark feature of esophagitis in GERD patients?
A) Microscopic injury without visible damage
B) Macroscopic erosions and ulcers of the esophageal mucosa
C) Hyperplasia of the esophageal squamous epithelium
D) Development of esophageal adenocarcinoma
Correct Answer: B) Macroscopic erosions and ulcers of the esophageal mucosa
Rationale: Esophagitis in GERD is characterized by macroscopic erosions and ulcers in the esophageal mucosa, which are visible on endoscopic examination. These lesions are the result of the inflammation caused by refluxed gastric contents.
In GERD patients, which pathway is most implicated in the development of esophagitis?
A) Direct damage from refluxed acid
B) Bacterial infection of the esophagus
C) Cytokine-mediated inflammatory response
D) T-cell mediated destruction of the esophageal lining
Correct Answer: C) Cytokine-mediated inflammatory response
Rationale: The development of esophagitis in GERD patients is primarily driven by a cytokine-mediated inflammatory pathway, which is supported by experimental evidence, rather than direct caustic injury to the esophageal epithelium.
Which of the following is NOT one of the three dominant mechanisms of esophagogastric junction (EGJ) incompetence?
A) Transient lower esophageal sphincter (LES) relaxations
B) LES hypotension
C) Anatomic distortion of the esophagogastric junction
D) Decreased gastric acid production
Correct Answer: D) Decreased gastric acid production
Rationale: The three dominant mechanisms of EGJ incompetence include transient LES relaxations, LES hypotension, and anatomic distortion of the EGJ (such as a hiatal hernia).
Which of the following extraesophageal syndromes has an established association with GERD?
A) Pulmonary fibrosis
B) Asthma
C) Sleep apnea
D) Cardiac arrhythmias
Correct Answer: B) Asthma
Rationale: Asthma is one of the extraesophageal syndromes with a well-established association with GERD. Other conditions with established links include chronic cough, laryngitis, and dental erosions.
Which condition has only a proposed (not established) association with GERD?
A) Chronic sinusitis
B) Laryngitis
C) Asthma
D) Dental erosions
Correct Answer: A) Chronic sinusitis
Rationale: Chronic sinusitis is among the conditions with a proposed, but not firmly established, association with GERD. Other proposed associations include pharyngitis, pulmonary fibrosis, sleep apnea, and cardiac arrhythmias.
What is the endoscopic hallmark of GERD?
A) Barrett’s esophagus
B) Erosive esophagitis at the esophagogastric junction
C) Hiatal hernia
D) Gastric ulcers
Correct Answer: B) Erosive esophagitis at the esophagogastric junction
Rationale: The endoscopic hallmark of GERD is erosive esophagitis at the esophagogastric junction. However, it is identified in only about one-third of GERD patients.
Which diagnostic tool can help distinguish among the various etiologies of esophagitis?
A) Barium swallow study
B) Endoscopic appearance and mucosal biopsy
C) CT scan of the abdomen
D) Esophageal manometry
Correct Answer: B) Endoscopic appearance and mucosal biopsy
Rationale: The distinction among etiologies of esophagitis is primarily based on endoscopic appearance. Mucosal biopsies are helpful in evaluating for other causes, such as infectious or eosinophilic esophagitis.
Which of the following is the most severe histologic consequence of GERD?
A) Erosive esophagitis
B) Peptic strictures
C) Barrett’s metaplasia
D) Chronic esophagitis
Correct Answer: C) Barrett’s metaplasia
Rationale: Barrett’s metaplasia is the most severe histologic consequence of GERD due to its association with a significantly increased risk of esophageal adenocarcinoma.
What is the endoscopic hallmark of Barrett’s esophagus?
A) Salmon-colored mucosa extending proximally from the gastroesophageal junction
B) Ulceration and strictures at the esophagogastric junction
C) White plaques on the esophageal mucosa
D) Nodular masses in the lower esophagus
Correct Answer: A) Salmon-colored mucosa extending proximally from the gastroesophageal junction
Rationale: Barrett’s esophagus is recognized endoscopically by the presence of salmon-colored mucosa extending proximally from the gastroesophageal junction.
Barrett’s metaplasia increases the risk of developing which type of cancer?
A) Squamous cell carcinoma of the esophagus
B) Gastric adenocarcinoma
C) Esophageal adenocarcinoma
D) Small cell carcinoma
Correct Answer: C) Esophageal adenocarcinoma
Rationale: Barrett’s metaplasia is associated with a significantly increased risk of esophageal adenocarcinoma, which progresses through intermediate stages of low- and high-grade dysplasia.
Which of the following has become less common in the era of potent acid suppression therapy?
A) Barrett’s metaplasia
B) Erosive esophagitis
C) Esophageal adenocarcinoma
D) Low-grade dysplasia
Correct Answer: B) Erosive esophagitis
Rationale: Potent antisecretory medications have made erosive esophagitis and peptic strictures increasingly rare, although the incidence of Barrett’s esophagus and esophageal adenocarcinoma has increased.
What is the current recommended treatment for high-grade dysplasia in Barrett’s esophagus?
A) Esophagectomy
B) Endoscopic mucosal ablation therapy
C) Proton pump inhibitors (PPIs) alone
D) Chemotherapy
Correct Answer: B) Endoscopic mucosal ablation therapy
Rationale: Current guidelines recommend endoscopic mucosal ablation therapy as the standard treatment for high-grade dysplasia in Barrett’s esophagus, as it is effective and associated with less morbidity and mortality compared to esophagectomy.
What is the typical progression of Barrett’s metaplasia to esophageal adenocarcinoma?
A) Barrett’s metaplasia → Ulceration → Adenocarcinoma
B) Barrett’s metaplasia → Low-grade dysplasia → High-grade dysplasia → Adenocarcinoma
C) Barrett’s metaplasia → Stricture formation → Adenocarcinoma
D) Barrett’s metaplasia → Chronic esophagitis → Adenocarcinoma
Correct Answer: B) Barrett’s metaplasia → Low-grade dysplasia → High-grade dysplasia → Adenocarcinoma
Rationale: Barrett’s metaplasia progresses to esophageal adenocarcinoma through intermediate stages of low- and high-grade dysplasia. Early identification and management of dysplasia are critical to prevent cancer progression.
Which of the following foods should be avoided in GERD management because they reduce lower esophageal sphincter (LES) pressure?
A) Citrus fruits
B) Tomato-based foods
C) Fatty foods
D) Spicy foods
Correct Answer: C) Fatty foods
Rationale: Fatty foods reduce LES pressure, making them “refluxogenic.” Other foods in this category include alcohol, spearmint, peppermint, and possibly coffee and tea.
Which class of medications is the most effective in managing GERD symptoms?
A) Antacids
B) Histamine-2 receptor antagonists (H2RAs)
C) Proton pump inhibitors (PPIs)
D) Prokinetic agents
Correct Answer: C) Proton pump inhibitors (PPIs)
Rationale: PPIs are the most effective class of medications for GERD management, providing superior symptom relief and esophagitis healing compared to H2RAs and placebo.
What is a surgical alternative to PPI therapy in the management of chronic GERD?
A) Hiatal hernia repair
B) Laparoscopic Nissen fundoplication
C) Esophagectomy
D) Endoscopic mucosal resection
Correct Answer: B) Laparoscopic Nissen fundoplication
Rationale: Laparoscopic Nissen fundoplication is a surgical option for chronic GERD. It involves wrapping the proximal stomach around the distal esophagus to create an antireflux barrier.
Which of the following pathogens is the most common cause of infectious esophagitis in immunocompromised patients?
A) Escherichia coli
B) Candida species
C) Mycobacterium tuberculosis
D) Streptococcus pneumoniae
Correct Answer: B) Candida species
Rationale: Candida species are one of the most common pathogens causing infectious esophagitis, particularly in immunocompromised patients. Other common pathogens include herpesvirus and cytomegalovirus (CMV).
In patients with AIDS, infectious esophagitis is rare when the CD4 count is above which threshold?
A) 50 cells/μL
B) 100 cells/μL
C) 200 cells/μL
D) 500 cells/μL
Correct Answer: C) 200 cells/μL
Rationale: Infectious esophagitis is rare in AIDS patients with CD4 counts above 200 cells/μL but becomes more common as the CD4 count declines, particularly when it falls below 100 cells/μL.
Which symptom is most characteristic of infectious esophagitis, differentiating it from reflux esophagitis?
A) Heartburn
B) Dysphagia
C) Odynophagia
D) Chest pain
Correct Answer: C) Odynophagia
Rationale: Odynophagia (painful swallowing) is a hallmark symptom of infectious esophagitis. It is uncommon in reflux esophagitis, making it an important distinguishing feature.
Which organism is the most common cause of Candida esophagitis?
A) Candida glabrata
B) Candida tropicalis
C) Candida albicans
D) Candida krusei
Correct Answer: C) Candida albicans
Rationale: Candida albicans is the most common cause of Candida esophagitis, particularly in immunocompromised or compromised hosts.
What clinical symptoms are most characteristic of Candida esophagitis?
A) Chest pain and hematemesis
B) Odynophagia and dysphagia
C) Persistent heartburn and regurgitation
D) Fever and weight loss
Correct Answer: B) Odynophagia and dysphagia
Rationale: Patients with Candida esophagitis typically present with odynophagia (painful swallowing) and dysphagia (difficulty swallowing).
What is the preferred initial diagnostic step if oral thrush is present and Candida esophagitis is suspected?
A) Empirical therapy with antifungal medication
B) CT scan of the esophagus
C) Endoscopy with biopsy
D) Esophageal manometry
Correct Answer: A) Empirical therapy with antifungal medication
Rationale: If oral thrush is present, empirical antifungal therapy is appropriate. However, persistent symptoms or a lack of response to treatment should prompt endoscopy with biopsy.
What is the characteristic endoscopic finding in Candida esophagitis?
A) Salmon-colored mucosa
B) Deep ulcers with irregular margins
C) White plaques or exudate with friability
D) Cobblestone appearance of the mucosa
Correct Answer: C) White plaques or exudate with friability
Rationale: Candida esophagitis has a characteristic endoscopic appearance of white plaques or exudate with mucosal friability.
What is the preferred treatment for Candida esophagitis?
A) Voriconazole 400 mg daily for 14–21 days
B) Oral fluconazole 400 mg on the first day, followed by 200 mg daily for 14–21 days
C) Intravenous amphotericin B for 7 days
D) Posaconazole 300 mg daily for 7 days
Correct Answer: B) Oral fluconazole 400 mg on the first day, followed by 200 mg daily for 14–21 days
Rationale: Oral fluconazole is the preferred treatment for Candida esophagitis, typically prescribed as 400 mg on the first day, followed by 200 mg daily for 14–21 days.
Which treatment option is appropriate for patients with Candida esophagitis refractory to fluconazole?
A) Increase the fluconazole dose
B) Voriconazole or posaconazole
C) Empirical treatment with antibiotics
D) Proton pump inhibitors
Correct Answer: B) Voriconazole or posaconazole
Rationale: Patients refractory to fluconazole may respond to voriconazole or posaconazole as alternative antifungal agents.
Which viruses are most commonly associated with herpetic esophagitis?
A) Epstein-Barr virus and cytomegalovirus
B) Herpes simplex virus (HSV) types 1 and 2, and varicella-zoster virus
C) Human papillomavirus and cytomegalovirus
D) HIV and hepatitis B virus
Correct Answer: B) Herpes simplex virus (HSV) types 1 and 2, and varicella-zoster virus
Rationale: HSV-1 and HSV-2 are common causes of herpetic esophagitis, with varicella-zoster virus (VZV) occasionally causing esophagitis in children with chickenpox or adults with zoster.
What is the characteristic endoscopic finding in herpetic esophagitis?
A) Large, deep ulcers with irregular borders
B) Vesicles and small, superficial ulcerations
C) White plaques with friability
D) Cobblestone appearance of the esophageal mucosa
Correct Answer: B) Vesicles and small, superficial ulcerations
Rationale: Endoscopic findings in herpetic esophagitis typically include vesicles and small, superficial ulcerations limited to the squamous epithelium.
Which histological finding is characteristic of HSV esophagitis?
A) Eosinophilic Cowdry’s type A inclusion bodies and multinucleated giant cells
B) Large, hyperchromatic nuclei with nuclear molding
C) Columnar metaplasia of the epithelium
D) Neutrophilic infiltration of the lamina propria
Correct Answer: A) Eosinophilic Cowdry’s type A inclusion bodies and multinucleated giant cells
Rationale: HSV esophagitis shows histological findings such as eosinophilic Cowdry’s type A inclusion bodies, ground-glass nuclei, and multinucleated giant cells on biopsy, especially from ulcer margins.
What is the recommended initial treatment for HSV esophagitis in patients with severe odynophagia?
A) Oral acyclovir, 200 mg five times daily
B) Oral fluconazole, 200 mg daily
C) Intravenous acyclovir, 5 mg/kg every 8 hours for 7–14 days
D) Topical antiviral ointment
Correct Answer: C) Intravenous acyclovir, 5 mg/kg every 8 hours for 7–14 days
Rationale: For patients with severe odynophagia, intravenous acyclovir is recommended to reduce morbidity associated with HSV esophagitis.
What is the typical endoscopic finding in CMV esophagitis?
A) Vesicles and small ulcerations
B) Cobblestone mucosa
C) Large serpiginous ulcers in normal mucosa, especially in the distal esophagus
D) White plaques or exudates with friability
Correct Answer: C) Large serpiginous ulcers in normal mucosa, especially in the distal esophagus
Rationale: CMV esophagitis is characterized by large serpiginous ulcers in otherwise normal mucosa, predominantly in the distal esophagus.
What is the pathognomonic histological finding in CMV esophagitis?
A) Eosinophilic Cowdry’s type A inclusion bodies
B) Multinucleated giant cells
C) Large nuclear or cytoplasmic inclusion bodies
D) Dense lymphocytic infiltration
Correct Answer: C) Large nuclear or cytoplasmic inclusion bodies
Rationale: CMV esophagitis is identified histologically by the presence of large nuclear or cytoplasmic inclusion bodies in biopsy specimens.
Which medications are effective in the treatment of CMV esophagitis?
A) Acyclovir and valacyclovir
B) Fluconazole and itraconazole
C) Ganciclovir and valganciclovir
D) Amphotericin B and voriconazole
Correct Answer: C) Ganciclovir and valganciclovir
Rationale: Ganciclovir (5 mg/kg IV every 12 hours) and valganciclovir (900 mg orally every 12 hours) are effective treatments for CMV esophagitis.
How long is therapy for CMV esophagitis typically continued?
A) 7–10 days
B) 2–3 weeks
C) 3–6 weeks
D) 1 year
Correct Answer: C) 3–6 weeks
Rationale: Therapy for CMV esophagitis is typically continued for 3–6 weeks, depending on the healing of the esophageal ulcers.
