IM- master the boards

Question 1

Hiatal hernia dx

Answer 1

Endoscopy or barium study

Question 2

Esophageal disorder alarm symptoms

Answer 2

Blood in stool
Weight loss - limited value
Anemia

Rule out cancer with endoscopy

Question 3

Hiatal hernia

Answer 3

Upper portion of stomach protrudes into chest through esophageal hiatus.

Can be due to obesity weakening the diaphragm

Can be indistinguishable from GERD ( heartburn, chest pain, dysphagia)

Question 4

Hiatal hernia tx

Answer 4

Weight loss and PPIs

If persistent: surgerical correction (Nissel fundoplication)

Question 5

Which esophageal hernia is most likely to require surgery?

Answer 5

Paraesophageal hernia&raquo_space;> gastric volvulus, obstruction, strangulation, hiatal hernia, perforation

Question 6

Achalasia vs. cancer

Answer 6

Achalasia:

Not assoc with cancer
Indistinguishable from GERD
Less than 50yo
Normal mucosa on endoscopy
Dysphagia to both S and L at SAME TIME

( manometry most accurate test)
Bird’s beak on barium esophagram

esophageal cancer:

Pts over 50 yo
Dysphagia first for solids THEN liquids
Association of long term alcohol and tobacco use
Biopsy required (endoscopy) - will show metaplasia (Barrett’s) or atypical histology

Question 7

Tx of achalasia

Answer 7

Pneumatic dilation

Or sx sectioning or myotomy but less safe but slightly more effective

Botox but only lasts 3-6 months

Question 8

Esophageal cancer tx

Answer 8

Resection if local

CT/ MRI - determine metz
PET- determine if resectable

Palliative stent if metz

Question 9

Esophageal spasm ddx

Answer 9

DES or nutcracker - clinically indistinguishable

Indistinguishable from atypical coronary artery spasm (prinzmental angina) or unstable angina

S/s :
- precipitated by drinking cold liquids
- sudden, severe chest pain
- normal EKG and stress test
- normal esophagram and endoscopy

Question 10

Esophageal spasm dx

Answer 10

Manometry is most accurate.

Can distinguish DES from nutcracker - will show different pattern of normal contraction

Barium study shows corkscrew at time of spasm

Question 11

Tx of esophageal spastic disorders

Answer 11

CCBs (TCAs as alternative)
If refractory (sildenafil)

Nitrates (similar to tx of prinzmetal angina)

PPIs in some cases

Question 12

Eosinophilic esophagitis s/s and dx

Answer 12

Dysphagia
Food impaction
Heartburn
Hx of asthma and allergic diseases

Endoscopy- multiple concentric rings
Bx- is most accurate for eosinophilia

Question 13

Eosinophilic esophagitis tx

Answer 13

Best initial tx - PPIs and elimination of allergens

If refractory- topical/ oral steroids

Question 14

The following pills cause esophagitis with prolonged use

Answer 14

Doxycycline
Alendronate
Potassium chloride

Question 15

Esophageal candidiasis

Answer 15

> 90% of esophageal infections in AIDS pts

Odynophagia
CD4 + < 100mm3

Oral candidiasis (thrush) need not to be present in esophageal candidiasis; one does not automatically follow from the other

Question 16

Esophageal candidiasis tx and mgmt algorithm

Answer 16

Dysphagia with HIV CD4+ < 100mm3

If yes- empirical fluconazole

If improvement - continue tx and add ART

If candidiasis is confirmed and un responsive to fluconazole—> IV amphotericin B

If no improvement- perform endoscopy with bx

If large ulcerations- CMV (tx ganciclovir or foscarnet)

If small ulcerations - HSV (tx acyclovir)

Question 17

Oral candidiasis tx

Answer 17

Nystatin “swish and swallow” - not sufficient for esophageal candidiasis