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.
- 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. Achalasia
B. Boerhaeve’s syndrome
C. Paraesophageal hiatal hernia
D. Esophageal cancer
E. GERD
E. GERD
Rationale: GERD often presents with heartburn, epigastric or substernal burning, and is commonly associated with dysphagia due to esophagitis, stricture formation, or complications like Barrett’s esophagus. Hoarseness can result from acid irritation affecting the larynx. This is more consistent with GERD, while achalasia (A) would primarily present with dysphagia to both solids and liquids without burning pain, and esophageal cancer (D) may cause progressive dysphagia and weight loss. Boerhaave’s syndrome (B) typically presents acutely with severe chest pain due to esophageal rupture, and paraesophageal hiatal hernia (C) would more likely involve obstructive symptoms than chronic burning pain.
- 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 the pathophysiology?
A. GE junction moves up through the esophageal hiatus along with some of the stomach
B. Radiation to the neck in childhood
C. A result of the increased resistance to esophageal emptying caused by the nonrelaxing LES
D. Acid, alcohol, and smoking
E. Abnormalities of the LES, impaired esophageal clearance, and abnormal esophageal barriers to acid exposure
E. Abnormalities of the LES, impaired esophageal clearance, and abnormal esophageal barriers to acid exposure
Rationale: GERD is often due to abnormalities in the lower esophageal sphincter (LES), impaired esophageal clearance, and ineffective esophageal barriers to acid exposure.
- 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. Which of the following tests is used to confirm the diagnosis?
A. EGD
B. Pharyngeal pH monitoring
C. Manometry
D. Bronchoscopy
A. EGD
Rationale: Esophagogastroduodenoscopy (EGD) is the gold standard for confirming GERD and assessing esophageal damage.
- 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 the most appropriate management?
A. Start Proton Pump Inhibitor
B. Thyroidectomy
C. Esophageal resection
D. Gastrectomy
A. Start Proton Pump Inhibitor
Rationale: Proton pump inhibitors are first-line management for GERD to reduce acid production and provide symptom relief.
- A 30-year-old man complains of regurgitation of saliva and of ingested but undigested food. An esophagogram reveals a “bird’s beak” deformity. Which of the following statements is true about this condition?
A. Chest pain is common in the advanced stages of this disease
B. More patients are improved by forceful dilatation than by surgical intervention
C. Manometry can be expected to show high resting pressure of the lower esophageal sphincter
D. Surgical treatment primarily consists of resection of the distal esophagus with reanastomosis to the stomach above the diaphragm
C. Manometry can be expected to show high resting pressure of the lower esophageal sphincter
Rationale: The “bird’s beak” deformity and symptoms are indicative of achalasia, which presents with a non-relaxing LES and high resting pressure on manometry.
- The least likely site where the esophagus may perforate during upper GI endoscopy is:
A. At the cricoid cartilage
B. Area of indentation of the right main bronchus and aortic arch
C. Pharyngoesophageal segment
D. Level of diaphragmatic hiatus
A. At the cricoid cartilage
Rationale: Esophageal perforation is less likely at the cricoid cartilage compared to other sites, which are anatomically more prone to injury during endoscopy.
- The component that completes the function of the LES includes the following, EXCEPT:
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
Rationale: The function of the LES is not significantly influenced by the width of the diaphragmatic hiatus.
- The lower border of this vertebra is the start of the esophagus that corresponds to the cricoid cartilage anteriorly:
A. 3rd cervical vertebra
B. 4th cervical vertebra
C. 5th cervical vertebra
D. 6th cervical vertebra
D. 6th cervical vertebra
Rationale: The esophagus begins at the lower border of the 6th cervical vertebra, corresponding to the cricoid cartilage.
- The following statements are true about the cervical portion of the esophagus, EXCEPT:
A. Approximately 5 cm long
B. The recurrent laryngeal nerves lie in the grooves between the trachea and esophagus
C. Right recurrent laryngeal nerve is closer to the esophagus than the left
D. Laterally on the left and right sides of the cervical esophagus are the carotid sheaths and lobes of the thyroid gland
C. Right recurrent laryngeal nerve is closer to the esophagus than the left
Rationale: The left recurrent laryngeal nerve is closer to the esophagus compared to the right.
- In the thoracic portion of the esophagus, it has an intimate relationship with the paravertebral fascia and follows the curvature of the spine. At what level of the thoracic vertebra does the esophagus move vertically to pass through the hiatus of the diaphragm?
A. 4th thoracic vertebra
B. 5th thoracic vertebra
C. 6th thoracic vertebra
D. 7th thoracic vertebra
E. 8th thoracic vertebra
F. 9th thoracic vertebra
E. 8th thoracic vertebra
Rationale: The esophagus moves vertically to pass through the diaphragmatic hiatus at the level of the 8th thoracic vertebra.
- A 50-year-old male has diagnosed esophageal cancer (34 cm from the incisor). Where is the most likely site of lymph node metastasis?
A. Deep cervical lymph nodes and Paracervical lymph nodes
B. Paracervical lymph nodes and subcarinal nodes
C. Subcarinal nodes and nodes in the inferior pulmonary ligaments
D. Peri-hiatal nodes and left gastric artery nodes
C. Subcarinal nodes and nodes in the inferior pulmonary ligaments
Rationale: For lower thoracic esophageal cancer, lymphatic spread often involves the subcarinal nodes and nodes in the inferior pulmonary ligaments.
- A 60-year-old female has diagnosed esophageal cancer (40 cm from the incisor). Where is the most likely site of lymph node metastasis?
A. Deep cervical lymph nodes and Paracervical lymph nodes
B. Paracervical lymph nodes and subcarinal nodes
C. Subcarinal nodes and nodes in the inferior pulmonary ligaments
D. Peri-hiatal nodes and left gastric artery nodes
D. Peri-hiatal nodes and left gastric artery nodes
Rationale: In esophageal cancer located near the gastroesophageal junction, lymphatic spread commonly involves peri-hiatal and left gastric artery nodes.
- Injury to this nerve causes affection of the cricopharyngeus and the upper one-third of the esophagus:
A. Glossopharyngeal nerve
B. Recurrent laryngeal nerve of vagus nerve
C. Cranial nerve GV
D. Cranial Nerve VII
B. Recurrent laryngeal nerve of vagus nerve
Rationale: The recurrent laryngeal nerve innervates the cricopharyngeus muscle, which is involved in the function of the upper esophagus.
- The following substances and hormones increase LES pressure:
A. Beta blockers
B. Peptides bombesin
C. Substance P
D. Antacids
E. AOTA
E. AOTA
Rationale: Beta blockers, peptides bombesin, Substance P, and antacids all contribute to increasing the lower esophageal sphincter (LES) pressure.
- According to the Los Angeles grading system of esophagitis, presence of ≥ 1 mucosal break that is continuous between the tops of 2 or more mucosal folds but that involves <75% of the esophageal circumference is classified as:
A. LA Grade A
B. LA Grade B
C. LA Grade C
D. LA Grade D
C. LA Grade C
Rationale: LA Grade C indicates at least one mucosal break that extends between the tops of two or more mucosal folds, involving less than 75% of the circumference.
- A 48-year-old man complains of upper abdominal postprandial pain, regurgitation, heartburn, bloating, and early satiety which is usually alleviated by vomiting. What is the most likely diagnosis?
A. Achalasia
B. Paraesophageal hiatal hernia
C. Esophageal cancer
D. GERD
E. Esophageal diverticula
B. Paraesophageal hiatal hernia
Rationale: The symptoms of postprandial pain, regurgitation, and relief with vomiting are suggestive of a paraesophageal hiatal hernia.
- A 48-year-old man complains of upper abdominal postprandial pain, regurgitation, heartburn, bloating, and early satiety which is usually alleviated by vomiting. What is the most appropriate test to confirm your diagnosis?
A. EGD
B. Barium Swallow
C. 24-hour pH monitoring
D. Manometry
E. Parapharyngeal pH monitoring
B. Barium Swallow
Rationale: A barium swallow is the preferred diagnostic test for identifying the anatomical features of a paraesophageal hiatal hernia.
- A 48-year-old man complains of upper abdominal postprandial pain, regurgitation, heartburn, bloating, and early satiety which is usually alleviated by vomiting. What is the most appropriate treatment?
A. Esophagomyotomy
B. Start PPI
C. Nissen Fundoplication
D. Esophageal resection
E. Repair of hiatal hernia
E. Repair of hiatal hernia
Rationale: The appropriate treatment for a paraesophageal hiatal hernia is surgical repair to prevent complications such as necrosis or strangulation.
- A 48-year-old man complains of upper abdominal postprandial pain, regurgitation, heartburn, bloating, and early satiety which is usually alleviated by vomiting. What is the dreaded complication if the condition is not corrected?
A. Ulcer
B. Necrosis
C. Pneumonia and pulmonary fibrosis
D. Barrett’s esophagus
E. Mediastinitis
B. Necrosis
Rationale: If a paraesophageal hiatal hernia is not treated, the herniated portion of the stomach can become strangulated, leading to necrosis.
- The first choice for palliation of disseminated gastroesophageal cancer with dysphagia is:
A. Esophageal stent
B. Chemotherapy
C. Radiation
D. Esophageal resection
A. Esophageal stent
Rationale: An esophageal stent is the preferred first choice for palliation in gastroesophageal cancer to alleviate dysphagia and improve the patient’s quality of life.
- The factor most predictive of postoperative complication in esophageal cancer surgery is:
A. Age >70 years old
B. FEV < 1.25L
C. Albumin <3.5g/dL
D. Ejection fraction <40%
C. Albumin <3.5g/dL
Rationale: Low serum albumin (<3.5g/dL) is predictive of poor nutritional status, which increases the risk of postoperative complications in esophageal cancer surgery.
- According to the Hill grade of Barrett’s esophagus, when there is NO FOLD and the lumen of the esophagus is open allowing the squamous epithelium to be viewed from below, its grade is:
A. Hill Grade A
B. Hill Grade B
C. Hill Grade C
D. Hill Grade D
D. Hill Grade D
Rationale: Hill Grade D is characterized by the absence of a fold, with the esophageal lumen being open, allowing visualization of the squamous epithelium from below.
- A 45-year-old male is diagnosed with GERD of 6 months duration. She presented with the following atypical symptoms, except:
A. Cough
B. Hoarseness
C. Chest pain
D. Aspiration
E. Dysphagia
E. Dysphagia
Rationale: Dysphagia is a typical symptom of GERD, while the other options are atypical manifestations.
- A permanently defective sphincter is defined by the following conditions and is the most common cause of GERD:
A. LES with a mean resting pressure of less than 6 mmHg
B. Overall sphincter length of <2 cm
C. Intraabdominal sphincter length of <1 cm
D. A and B
E. A and C
C. Intraabdominal sphincter length of <1 cm
Rationale: GERD can result from a permanently defective lower esophageal sphincter (LES), with an intraabdominal sphincter length of less than 1 cm being one of the most common causes.
- The following components are injurious when exposed to the esophagus. Which of the components causes severe epithelial injury?
A. Acid
B. Pepsin
C. Biliary secretions
D. A and B
E. A and C
D. A and B
Rationale: Both acid and pepsin can cause severe epithelial injury when exposed to the esophageal mucosa.
- A 52-year-old female diagnosed with Schatzki’s ring with dysphagia and gastroesophageal reflux syndrome. What would be the best treatment option?
A. Dilatation alone
B. Dilatation with antireflux measures
C. Antireflux procedure alone
D. Incision of the ring
E. Excision of the ring
B. Dilatation with antireflux measures
Rationale:
Schatzki’s ring can cause intermittent dysphagia, often treated effectively with dilatation to widen the ring and improve swallowing.
Since the patient also has GERD, adding antireflux measures can help manage both conditions and prevent recurrent symptoms.
- A 48-year-old female diagnosed with Schatzki’s ring with symptoms of dysphagia. What would be the best treatment option?
A. Dilatation alone
B. Dilatation with antireflux measures
C. Antireflux procedure alone
D. Excision of the ring
A. Dilatation alone
- This type of esophageal hiatal hernia is also known as a rolling esophageal hernia:
A. Type I
B. Type II
C. Type III
D. Type IV
B. Type II
Rationale: A Type II hiatal hernia is also referred to as a rolling or paraesophageal hernia, in which part of the stomach rolls into the chest next to the esophagus.
- Which of the following makes curative resection of an esophageal cancer likely?
A. Tumor length >8 cm
B. Involved lymph nodes <2
C. Recurrent laryngeal nerve palsy
D. Weight loss of >20%
B. Involved lymph nodes <2
Rationale: A smaller number of involved lymph nodes (<2) makes curative resection more likely in esophageal cancer.
- A 50-year-old female consulted because of difficulty swallowing, associated with spontaneous regurgitation of undigested food that interrupts eating. This patient most likely has:
A. Diaphragmatic hernia
B. Achalasia
C. Nutcracker esophagus
D. Zenker’s diverticulum
E. Esophageal cancer
D. Zenker’s diverticulum
- A 50-year-old female consulted because of difficulty swallowing, associated with spontaneous regurgitation of undigested food that interrupts eating
What is the best method to establish the diagnosis of Zenker’s diverticulum?
A. MRI
B. Barium swallow
C. History and physical examination
D. EGD
B. Barium swallow
Rationale: A barium swallow is often used to diagnose esophageal disorders, particularly structural abnormalities, by providing visualization of the esophagus.
- What type of hiatal hernia involves the herniation of colon and spleen into the thorax?
A. Type I
B. Type II
C. Type III
D. Type IV
D. Type IV
Rationale: Type IV hiatal hernia involves herniation of other abdominal organs, such as the colon or spleen, into the thorax.
- Esophageal adenocarcinoma occurs more commonly in the:
A. Cervical Esophagus
B. Upper Thoracic Esophagus
C. Mid Thoracic Esophagus
D. Lower Thoracic Esophagus
D. Lower Thoracic Esophagus
Rationale: Esophageal adenocarcinoma is most commonly found in the distal esophagus, which is associated with gastroesophageal reflux disease (GERD).
- Esophageal squamous cell carcinoma occurs more commonly in the:
A. Cervical Esophagus
B. Upper Thoracic Esophagus
C. Mid Thoracic Esophagus
D. Lower Thoracic Esophagus
B. Upper Thoracic Esophagus
- In a patient undergoing curative resection for an adenocarcinoma of the gastroesophageal junction, how much proximal normal esophagus should be removed?
A. 3 cm
B. 5 cm
C. 8 cm
D. Entire thoracic esophagus
C. 8 cm
Rationale: In patients undergoing curative resection for adenocarcinoma of the gastroesophageal junction, it is recommended to obtain a large margin of normal tissue to prevent local recurrence. A margin of at least 8-10 cm of normal esophagus above the tumor is typically considered to ensure that any potential submucosal spread and skip lesions are adequately excised, reducing the likelihood of recurrence at the anastomosis site.
Safe margins for resection
Esophagus – 10 cm
Stomach – 6cm
Colon (specially rectal CA) – >2 cm
- A 60-year-old male presents with progressive dysphagia of 8 months duration. This was accompanied by weight loss and occasional coughing, particularly during meals. The patient is malnourished, with stable vital signs, a flat, soft, non-tender abdomen, and no organomegaly. The most probable diagnosis is:
A. Achalasia
B. Esophageal sarcoma
C. Esophageal cancer
D. Barrett’s esophagus
E. GERD
C. Esophageal Cancer
- A 60-year-old male presents with progressive dysphagia of 8 months duration. This was accompanied by weight loss and occasional coughing, particularly during meals. The patient is malnourished, with stable vital signs, a flat, soft, non-tender abdomen, and no organomegaly. Which diagnostic procedure will more or less confirm your diagnosis?
A. EGD with biopsy
B. Endoscopic ultrasound
C. Esophagogram
D. CT Scan
E. Manometry
A. EGD with biopsy
- A patient presents at the ER after 500 mL of bright red blood. Endoscopy shows a tear at the GE junction. The most appropriate treatment is:
A. Observation
B. Placement of Sengstaken-Blakemore tube
C. Surgical gastrotomy and oversewing of tears
D. Administration of antiemetics
A. Observation
- A patient suffering from mid-esophageal carcinoma who is being considered for 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: In cases of mid-esophageal cancer, segmental esophageal resection can be considered to achieve complete removal of the tumor while maintaining some of the normal esophagus, depending on the location and extent of the cancer.
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- A patient suffering from mid-esophageal cancer underwent a barium esophagram prior to undergoing a GI endoscopy. What is the expected finding?
A. Bird’s beak appearance
B. Rat tail appearance
C. Mucosal outpouching
D. Filling defect
D. Filling defect
Rationale: A filling defect is a common finding in esophageal cancer, which indicates the presence of an obstructive mass. The “rat tail” or “bird’s beak” appearances are associated with achalasia, while mucosal outpouching is associated with diverticula.
- In the repair of a hiatal hernia, which approach is the most preferred?
A. Laparoscopic Abdominal
B. Laparoscopic Thoracic
C. Open Abdominal
D. Open Thoracic
A. Laparoscopic Abdominal
Rationale:
The most preferred approach for repairing a hiatal hernia is the laparoscopic abdominal approach. This minimally invasive technique has become the gold standard due to several advantages:
Better Visualization: The abdominal approach provides direct access to the hiatal area, allowing for precise dissection and repair.
Lower Morbidity: It is associated with less postoperative pain and fewer complications compared to thoracic approaches.
Quicker Recovery: Patients generally experience shorter hospital stays and faster return to normal activities.
Enhanced Outcomes: The laparoscopic method has shown excellent long-term results in terms of symptom relief and hernia recurrence rates.
- A 56-year-old male patient is undergoing cervical esophagostomy. Where would be the ideal site for the procedure?
A. Right upper portion of the neck
B. Right lower portion of the neck
C. Left upper portion of the neck
D. Left lower portion of the neck
D. Left lower portion of the neck
Rationale: A cervical esophagostomy is ideally performed on the left lower portion of the neck. The esophagus is anatomically positioned slightly to the left of the midline in the neck, making the left side more accessible. The lower portion is preferred to allow better drainage and to minimize the risk of aspiration.
- A 29-year-old female diagnosed with a motility disorder of the esophagus underwent an esophagectomy. Where is the appropriate site for the surgical incision?
A. Left Thoracotomy
B. Right Thoracotomy
C. Midline abdominal incision
D. A and C
E. B and C
E. B and C (Right Thoracotomy and Midline Abdominal Incision)
Rationale: For esophagectomy in a patient with a motility disorder, the appropriate surgical incisions are a right thoracotomy and a midline abdominal incision. The right thoracotomy provides access to the middle and upper portions of the esophagus, while the abdominal incision allows for mobilization of the stomach or another conduit for reconstruction. This combined approach is common in procedures like the Ivor Lewis esophagectomy.
- Which of the following surgical maneuvers is employed in motor disorders of the esophagus?
A. Imbrication
B. Marsupialization
C. Myotomy
D. Resection
C. Myotomy
Rationale: A myotomy, specifically a Heller’s myotomy, is a surgical procedure used to treat motor disorders of the esophagus such as achalasia. It involves cutting the muscles at the lower end of the esophageal sphincter to relieve functional obstruction and allow food to pass into the stomach. Imbrication and marsupialization are unrelated to esophageal motor disorders, and resection is more invasive than necessary for treating motility issues.
- An 8-year-old male accidentally swallowed a 25-centavo coin. Where would it be LEAST likely to lodge in the esophagus?
A. At the entrance of the cricopharyngeal muscle
B. At the crossing of the left main stem bronchus
C. At the hiatus of the diaphragm
D. A and B
E. B and C
E. B and C (At the crossing of the left main stem bronchus and at the hiatus of the diaphragm)
Rationale: The least likely locations for a swallowed coin to lodge are at the crossing of the left main stem bronchus (B) and at the hiatus of the diaphragm (C). The most common site for foreign body impaction in children is at the level of the cricopharyngeal muscle (A), which is the narrowest part of the esophagus. While the areas at B and C are anatomical constrictions, they are less commonly involved compared to the upper esophageal sphincter.
- Traction diverticula in the esophagus are a result of:
A. Trauma, usually iatrogenic
B. Genetic abnormality
C. Motility disorders
D. Inflammation
D. Inflammation
Rationale: Traction diverticula in the esophagus are caused by inflammation in adjacent mediastinal structures, such as lymph nodes affected by tuberculosis or histoplasmosis. The inflammatory process leads to scarring and pulling (traction) on the esophageal wall, resulting in a diverticulum. They are true diverticula involving all layers of the esophageal wall.
- 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 likely 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: Malignant lymph nodes in the superior gastric nodes suggest that the esophageal cancer is located in the lower thoracic or abdominal esophagus. These nodes drain lymph from the lower portion of the esophagus and the proximal stomach. Therefore, involvement of these nodes indicates a primary tumor in these regions.
- Currently, the best results following treatment of achalasia are achieved by:
A. Distal Esophagomyotomy
B. Injection of the LES with botulinum toxin
C. Forceful disruption of the LES (bougienage)
D. Distal esophagomyotomy and some type of fundoplication
D. Distal esophagomyotomy and some type of fundoplication
Rationale: The best results for treating achalasia are achieved with a distal esophagomyotomy (Heller’s myotomy) combined with a fundoplication procedure. The myotomy relieves the functional obstruction by cutting the muscle fibers of the lower esophageal sphincter, while the fundoplication prevents gastroesophageal reflux by reinforcing the barrier between the stomach and esophagus.
- Which of the following decreases the HPZ (high-pressure zone) of the esophagus?
A. Gastrin
B. Secretin
C. Motilin
D. Histamine
B. Secretin
Rationale: Secretin decreases the pressure of the high-pressure zone (HPZ) of the esophagus by relaxing the lower esophageal sphincter (LES). This hormone inhibits gastric acid secretion and promotes bicarbonate secretion but also has a relaxing effect on smooth muscle. Gastrin and motilin increase LES pressure, while histamine primarily stimulates gastric acid secretion without significantly affecting LES tone.
