LE3 Esophagus Flashcards
Factor most predictive of postoperative complications in carcinoma of the esophagus:
a. Age
b. Nutritional Status
c. Family history
d. Gender
b. Nutritional Status
Rationale: Nutritional status is the most predictive factor for postoperative complications in esophageal cancer patients. Malnourished patients have a higher risk of infections, poor wound healing, and overall morbidity due to compromised immunity and muscle wasting.
The surgical treatment of esophageal cancer is dependent upon the following factors, except:
A. The location of the cancer
B. The depth of invasion
C. Lymph node metastasis
D. Patient’s age
D. Patient’s age
Rationale: While age is considered in the overall risk assessment, it is not a direct determinant for surgical treatment. The treatment is mainly based on cancer location, depth of invasion, and lymph node metastasis, which dictate the surgical approach and prognosis.
Lymphatics of the distal greater curvature of the stomach drain into which group of nodes?
A. Right gastroepiploic chain
B. Left gastroepiploic chain
C. Right gastric nodes
D. Splenic hilum
A. Right gastroepiploic chain
Rationale: According to the lymphatic drainage patterns of the stomach, the greater curvature half of the distal stomach typically drains to nodes along the right gastroepiploic chain. This is in contrast to the proximal greater curvature, which drains into the left gastroepiploic or splenic hilum nodes.
Which of the following statements is true about the blood supply of the stomach?
A. Angiographic control of gastric bleeding requires embolization of just one of the main feeding arteries
B. The stomach can be used as a shunt to decompress patients with portal hypertension
C. Even if just one artery is ligated, vascular compromise will ensue
D. Most arteries are end arteries with no significant collaterals
B. The stomach can be used as a shunt to decompress patients with portal hypertension
Rationale: The stomach is used in surgical procedures like a shunt for decompression in patients with portal hypertension. This is done by diverting blood flow to reduce pressure in the portal venous system.
Fibers of the posterior vagus nerve found in the posterior aspect of the fundus are known as the:
A. Nerve of Latarjet
B. Criminal nerve of Grassi
C. Celiac branch of the right vagus
D. Hepatic branch of the left vagus
B. Criminal nerve of Grassi
Rationale: The criminal nerve of Grassi is a branch of the posterior vagus that innervates the gastric fundus and must be considered in vagotomy procedures to prevent recurrent ulcers.
Which of the following structures forms the microscopic boundary for invasive gastric carcinoma?
A. Lamina propria
B. Surface epithelium
C. Submucosa
D. Muscularis mucosa
C. Submucosa
Rationale: The submucosa is the boundary used to define invasive gastric carcinoma, as invasion beyond this layer classifies the tumor as invasive.
Increases lower esophageal sphincter pressure:
a. Somatostatin
b. Secretin
c. Glucagon
d. Gastrin
d. Gastrin
Rationale: Gastrin significantly increases lower esophageal sphincter (LES) pressure, playing a role in the prevention of gastroesophageal reflux by enhancing sphincter tone.
Here’s a high-yield rationale for each choice:
1. Somatostatin: Primarily inhibits gastric acid and hormone secretion; no effect on LES pressure.
2. Secretin: Stimulates bicarbonate secretion; does not increase LES pressure.
3. Glucagon: Relaxes smooth muscle, decreasing LES pressure.
4. Gastrin: Increases LES pressure by promoting sphincter contraction. (Correct answer)
Measured during manometry:
a. Amplitude and length of the LES
b. Characteristics of peristaltic activity in the body of the esophagus
c. Extent and duration of relaxation of the UES with swallowing
d. All of the above
d. All of the above
Rationale: Esophageal manometry assesses various aspects, including LES amplitude and length, peristaltic activity in the esophagus, and the function of the upper esophageal sphincter (UES).
GIST (Gastrointestinal Stromal Tumors) are derived from which cells?
A. Interstitial cells of Cajal
B. Smooth muscle cells
C. Fibroblasts
D. Endothelial cells
A. Interstitial cells of Cajal
Rationale: GISTs originate from the interstitial cells of Cajal, which are pacemaker cells responsible for regulating peristalsis in the gastrointestinal tract.
Nitric oxide is considered an inhibitory neurotransmitter that:
A. Decreases lower esophageal sphincter tone
B. Increases gastrointestinal motility
C. Promotes vascular constriction
D. Stimulates acid secretion
A. Decreases lower esophageal sphincter tone
Rationale: Nitric oxide acts as an inhibitory neurotransmitter that decreases lower esophageal sphincter tone, facilitating the passage of food into the stomach during swallowing.
The primary function of leptin is to:
A. Decrease appetite
B. Increase energy expenditure
C. Regulate blood glucose levels
D. Stimulate gastric acid secretion
A. Decrease appetite
Rationale: Leptin, primarily synthesized by adipocytes and chief cells, plays a crucial role in decreasing appetite by acting on the hypothalamus to regulate energy intake and expenditure. It signals satiety and helps regulate body weight.
True statements about peptic ulcer disease include:
A. H. pylori is the most common cause
B. Stress is the primary cause
C. NSAIDs have no impact on ulcer formation
D. Surgery is always required
A. H. pylori is the most common cause
Rationale: Helicobacter pylori infection is the leading cause of peptic ulcer disease, followed by NSAID use. Stress is not a primary cause, and surgery is rarely required due to the effectiveness of medications like proton pump inhibitors and antibiotics for H. pylori eradication.
Treatment options for duodenal cancer include:
a. Vagotomy and drainage
b. Vagotomy with oversewing and drainage
c. Vagotomy and antrectomy
d. Patch and highly selective vagotomy
C. Vagotomy and antrectomy
Rationale: Vagotomy with antrectomy is often used in treating duodenal cancers. This approach reduces acid production by severing vagal nerve fibers and removing part of the stomach to prevent ulcer recurrence and manage cancer.
Gold standard for diagnosing gastric cancer is:
a. CT scan
b. MRI
c. Endoscopy
d. Biopsy
c. Endoscopy
Which of the following is not considered a prognostic indicator for stomach cancer?
A. Tumor grade
B. Tumor depth
C. Lymph node involvement
D. None of the above
D. None of the above
Explanation:
Tumor grade (A), tumor depth (B), and lymph node involvement (C) are all critical prognostic indicators for stomach cancer. These factors significantly impact staging and treatment decisions, as they correlate with the likelihood of metastasis and overall prognosis.
Therefore, all listed options (A, B, and C) are indeed prognostic indicators, making “None of the above” (D) the correct answer.
The normal stomach secretes the following substances, except:
A. Pepsinogen
B. Intrinsic factor
C. Lipase
D. Hydrochloric acid
E. Bicarbonate
E. Bicarbonate
Following surgical maneuver is employed in motor disorders of the esophagus:
A. Resection
B. Myotomy
C. Imbrication
D. Fundoplication
B. Myotomy
Rationale: Myotomy, such as Heller myotomy, is performed to treat esophageal motility disorders like achalasia by cutting the muscles of the lower esophageal sphincter to improve swallowing.
A patient came into the ER after vomiting 500 ml of bright red blood. Endoscopy was performed and showed a tear at the gastroesophageal junction. The most appropriate treatment is:
A. Observation
B. Reassurance and discharge
C. Surgical gastronomy
D. Administration of antiemetics
A. Observation
Rationale: In cases like Mallory-Weiss tears at the gastroesophageal junction, observation is often appropriate as most cases stop bleeding spontaneously. Administering antiemetics can help prevent further vomiting and reduce the risk of rebleeding.
A patient suffering from mid-esophageal cancer who is being considered for a possible curative resection should have at least a:
A. G-E resection
B. Total esophageal resection
C. Segmental esophageal resection
D. Wide resection of the tumor
C. Segmental Esophageal resection
Rationale: For mid-esophageal cancer, a segmental esophageal resection is often employed when the cancer is localized to a specific portion of the esophagus. This procedure allows for the removal of the cancerous segment while preserving as much of the esophagus as possible. It is part of the esophagectomy family of surgeries and is chosen based on tumor size, location, and extent.
A patient suffering from mid-esophageal cancer underwent a barium esophagram prior to a GI endoscopy. The expected finding is:
A. Bird’s beak appearance
B. Rat tail appearance
C. Mucosal outpouching
D. Filling defect
D. Filling defect
Rationale: A filling defect on barium swallow indicates a space-occupying lesion like a tumor, which causes irregular narrowing and obstruction.
Initial management for a bleeding peptic ulcer includes:
A. Oversew ulcer
B. Anti-emetics
C. Sengstaken-Blakemore tube
D. Decompression
A. Oversew ulcer
Rationale: In cases of severe peptic ulcer bleeding, surgical intervention, such as oversewing the ulcer, may be required after non-surgical measures like endoscopic treatment (e.g., coagulation or clipping) fail. Other options like antiemetics or decompression do not address the active bleeding, and the Sengstaken-Blakemore tube is typically reserved for esophageal variceal bleeding, not peptic ulcers.
In a patient with a history of smoking and NSAID use for 2 weeks, what medication should be considered if the patient is:
A. Over age of 50
B. Concurrent steroid use
C. Taking aspirin
D. Taking ampicillin
B. Concurrent steroid use
Rationale: If the patient is using NSAIDs and steroids concurrently, they are at an increased risk of gastrointestinal ulcers and bleeding. Proton pump inhibitors (PPIs) or H2 blockers are recommended to reduce the risk of NSAID-induced gastric damage in this situation. This is particularly important in patients over 50 years of age, or those taking aspirin, which further increases the risk of gastrointestinal complications.
What is the best management for low-grade gastric lymphoma of the stomach?
A. Radiation
B. Chemotherapy
C. Surgical resection
D. Watchful waiting
A. Radiation
Management of watermelon stomach (Gastric antral vascular ectasia)?
A. Surgical resection
B. Endoscopic laser therapy
C. Medication (e.g., proton pump inhibitors)
D. Balloon dilatation
B. Endoscopic laser therapy
Rationale: Endoscopic laser therapy is the most effective treatment for Gastric antral vascular ectasia (GAVE), commonly referred to as watermelon stomach. This approach controls bleeding by coagulating the vascular ectasias, reducing the risk of recurrent gastrointestinal bleeding.
The following chemicals & hormones increase the LES pressure, except:
A. Antacids
B. Gastrin
C. Theophylline
D. Beta blockers
E. Metoclopramide
C. Theophylline
Rationale: Theophylline decreases LES pressure, while substances like gastrin and motilin increase it. Antacids and medications like metoclopramide can also increase LES tone, but theophylline relaxes the LES, often worsening conditions like GERD.
A 38-year-old female presents with symptoms that warrant mandatory upper gastrointestinal endoscopy. Which of the following symptoms qualifies?
A. Heartburn
B. GERD
C. Peptic Ulcer Disease (PUD)
D. Dysphagia
C. Peptic Ulcer Disease (PUD)
A 45-year-old female complains of burning epigastric and substernal pain for 6 months. Two months prior to consultation, dysphagia and hoarseness were also noted. What is your diagnosis?
A. GERD
B. Peptic Ulcer Disease
C. Gastric Cancer
D. Esophageal Stricture
A. GERD
Rationale: GERD can present with typical symptoms like burning pain (heartburn) and may progress to dysphagia and hoarseness due to chronic acid reflux affecting the esophagus and larynx.
Most common perforation during upper GI gastroscopy is:
A. Esophageal perforation
B. Duodenal perforation
C. Gastric perforation
D. Diverticular perforation
D. Diverticular perforation
The most common site of perforation in the esophagus during upper GI endoscopy is:
A. Cricoid cartilage
B. Area of indentation of the right main bronchus and aortic arch
C. Pharyngoesophageal segment
D. Level of diaphragmatic hiatus
B. Area of indentation of the right main bronchus and aortic arch
Rationale: The area of indentation by the right main bronchus and aortic arch is a common site of perforation due to its anatomical narrowing, increasing susceptibility during endoscopy.
The components that complete the function of the lower esophageal sphincter (LES) include the following:
A. Width of diaphragmatic hiatus
B. Length of intraabdominal esophagus
C. Resting pressure in the LES
D. Length of the area of increased tone in the lower esophageal muscle
A. Width of diaphragmatic hiatus
Traction diverticula in the esophagus are a result of:
A. Trauma, usually iatrogenic
B. Genetic abnormality
C. Motility disorder
D. Inflammatory processes
D. Inflammatory processes
Rationale: Traction diverticula are typically caused by inflammatory processes in the mediastinum, which can result in scarring and pulling on the esophagus, creating the diverticulum. Fistulas associated with traction diverticula are often linked to mediastinal inflammation.
A 50-year-old male complained of dysphagia and was eventually diagnosed with esophageal cancer. On CT scan of the chest and abdomen, malignant-looking lymph nodes were seen in the superior gastric nodes. Where is the esophageal malignancy located?
A. Cervical esophagus
B. Upper thoracic esophagus
C. Lower thoracic esophagus
D. Abdominal esophagus
E. C and D
E. C and D (Lower thoracic esophagus and abdominal esophagus)
Rationale: The involvement of the superior gastric nodes suggests that the malignancy is located in the lower thoracic or abdominal esophagus, as these areas drain into the superior gastric lymph nodes.
The cell of origin of gastrointestinal stromal tumors (GIST) is:
A. Interstitial cells of Cajal
B. G cells
C. Smooth muscle cells
D. D cells
A. Interstitial cells of Cajal
Rationale: GISTs originate from the interstitial cells of Cajal, which function as pacemaker cells in the gastrointestinal tract, coordinating smooth muscle contraction.
Most common symptoms for gastric carcinoma include:
A. Anorexia and weight loss
B. Bleeding
C. Obstruction
D. Dysphagia
A. Anorexia and weight loss
Rationale: The most common symptoms of gastric carcinoma include anorexia, weight loss, and early satiety. These symptoms are often accompanied by other nonspecific complaints like nausea and anemia.
Dysphagia and weight loss can be a symptom of:
A. Esophageal cancer
B. Peptic ulcer disease
C. Gastroesophageal reflux disease (GERD)
D. Achalasia
A. Esophageal cancer
Rationale: Dysphagia and weight loss are hallmark symptoms of esophageal cancer, often occurring due to the tumor obstructing the esophagus.
The first choice for palliation for disseminated gastroesophageal cancer with dysphagia is:
A. Chemotherapy
B. Radiation therapy
C. Esophageal stent
D. Palliative care
C. Esophageal stent
Rationale: For patients with inoperable gastroesophageal cancer, esophageal stenting is the first-line palliative treatment to alleviate dysphagia and improve the patient’s quality of life.
Diagnostics established for achalasia include:
A. Upper endoscopy
B. Barium esophagogram
C. (High-resolution) manometry
D. All of the above
D. All of the above
Rationale: The diagnosis of achalasia is confirmed using upper endoscopy, barium esophagogram, and high-resolution manometry, which together assess esophageal motility and structure.
Most common esophageal cancer is:
A. Adenocarcinoma
B. Squamous cell carcinoma
C. Sarcoma
D. Lymphoma
A. Adenocarcinoma
Rationale: Adenocarcinoma is the most common type of esophageal cancer, especially in White populations, while squamous cell carcinoma is more prevalent in African Americans.
Resection of the entire esophagus is called:
A. Gastrectomy
B. Esophagectomy
C. Duodenectomy
D. Colorectomy
B. Esophagectomy
Rationale: Esophagectomy refers to the surgical removal of the esophagus, often followed by reconstruction using the stomach or part of the intestine.
Most common cause of esophageal perforation is:
A. Spontaneous perforation
B. Foreign bodies
C. Trauma
D. None of the above
A. Spontaneous perforation
Problem with peristalsis is known as:
A. Achalasia
B. Gastroesophageal reflux
C. Dysphagia
D. Esophagitis
A. Achalasia
Rationale: Achalasia is the most common motility disorder, where the esophagus fails to move food properly through peristalsis, and the lower esophageal sphincter does not relax to allow food into the stomach.
A patient presents to the ER after vomiting 500 mL of bright red blood. Endoscopy shows a tear at the gastroesophageal junction. The most appropriate treatment is:
A. Observation
B. Placement of Sengstaken-Blakemore tube
C. Surgical gastronomy and oversewing of the tear
D. Administration of antiemetics
B. Observation
• Correct. Most Mallory-Weiss tears, which are mucosal lacerations typically caused by vomiting or retching, stop bleeding spontaneously. Observation, along with supportive care such as blood replacement if necessary, is the appropriate treatment in cases where there is no ongoing bleeding. Endoscopic confirmation of the tear without residual bleeding supports a nonoperative approach.
Locations of anatomic narrowing of the esophagus seen on an esophagram include all of the following EXCEPT:
A. Lower esophageal sphincter
B. Crossing of the right mainstem bronchus and aortic arch
C. Thoracic outlet
D. Cricopharyngeal muscle
C. Thoracic outlet
Rationale: The three normal areas of esophageal narrowing are at the cricopharyngeal muscle, where the esophagus enters, at the crossing of the left mainstem bronchus and aortic arch, and at the lower esophageal sphincter. The thoracic outlet is not a site of esophageal narrowing.
The cervical esophagus receives its blood supply primarily from the:
A. Internal carotid artery
B. Inferior thyroid artery
C. Superior thyroid artery
D. Inferior cervical artery
E. Facial artery
B. Inferior thyroid artery
Rationale: The primary blood supply to the cervical esophagus comes from the inferior thyroid artery. This artery provides the vascularization necessary for the upper part of the esophagus. Other regions of the esophagus receive blood from different arterial sources like the bronchial arteries and the left gastric artery for the thoracic and abdominal portions, respectively.
All of the following cranial nerves are involved in the swallowing mechanism EXCEPT:
A. V
B. VII
C. VIII
D. X
E. XI
F. XII
C. VIII (Vestibulocochlear)
Rationale: Cranial nerves V (Trigeminal), VII (Facial), IX (Glossopharyngeal), X (Vagus), XI (Accessory), and XII (Hypoglossal) are all involved in the swallowing process. Cranial nerve VIII (Vestibulocochlear) is related to hearing and balance and does not play a role in the swallowing mechanism. The coordination of these nerves ensures a smooth and ordered swallowing process, and damage to these nerves can result in swallowing difficulties.
All of these are parts of the human antireflux mechanism EXCEPT:
A. Adequate gastric reservoir
B. Mechanically functioning lower esophageal sphincter (LES)
C. Mucus-secreting cells of the distal esophagus
D. Efficient esophageal clearance
C. Mucus secreting cells of the distal esophagus
Rationale: The human antireflux mechanism consists of the lower esophageal sphincter (LES), efficient esophageal clearance, and an adequately functioning gastric reservoir. While mucus-secreting cells are important for protecting the esophagus, they are not a primary component of the antireflux mechanism.
Physiologic reflux happens most commonly when a person is:
A. Awake and supine
B. Awake and upright
C. Asleep and supine
D. Asleep and semi-erect
B. Awake and upright
Rationale: Physiologic reflux episodes are more common when a person is awake and upright due to the effects of gravity and transient relaxation of the lower esophageal sphincter (LES). The pressure gradient between the stomach and esophagus favors reflux in the upright position, while in the supine position, this gradient diminishes.
All of the following hormones decrease LES tone EXCEPT:
A. Gastrin
B. Estrogen
C. Somatostatin
D. CCK
E. Glucagon
A. Gastrin
Rationale: Gastrin and motilin are known to increase lower esophageal sphincter (LES) pressure, enhancing the barrier against reflux. In contrast, hormones such as estrogen, somatostatin, cholecystokinin (CCK), glucagon, and others decrease LES tone, contributing to the possibility of gastroesophageal reflux.
The most common cause of a deficient LES is:
A. Inadequate overall length
B. Mean resting pressure >6 mm Hg
C. Inadequate intra-abdominal length
D. Failure of receptive relaxation
C. Inadequate intra-abdominal length
Rationale: A deficient lower esophageal sphincter (LES) is often caused by an inadequate intra-abdominal length of the LES. Inadequate exposure of the LES to intra-abdominal pressure compromises its ability to maintain the barrier against reflux, especially in the presence of a hiatal hernia, where the LES is displaced into the chest cavity, losing its functional integrity.