Scleroderma (Progressive Systemic Sclerosis)

Question 1

80–90% of patients with scleroderma will develop diminished esophageal peristalsis from

Answer 1

atrophy and fibrosis of the esophageal smooth muscle.

Question 2

What is the Clinical Presentation of Scleroderma?

Answer 2

1-dysphagia
2-main clue is GERD symptoms with a history of scleroderma
3-LES will not contract nor relax

Question 3

what is the most accurate diagnostic test of scleroderma?

Answer 3

motility study.

Question 4

what is the Treatment of scleroderma?

Answer 4

1-proton-pump inhibitor e.g. omeprazole.

2- Metoclopramide a promotility agent.

Question 5

what are the Diffuse Esophageal Spasm and Nutcracker Esophagus?

Answer 5

idiopathic abnormalities of the neural processes of the esophagus

Question 6

what is the difference between Diffuse Esophageal Spasm and Nutcracker Esophagus

Answer 6

the manometric pattern

Question 7

what is the Clinical Presentation of Diffuse Esophageal Spasm?

Answer 7

1-Intermittent chest pain and dysphagia
2-pain simulate myocardial infarction but it bears no relationship with exertion
3-no relation with eating, ruling out odynophagia
4-pain triggered by drinking cold liquids.

Question 8

what is the diagnosis of Diffuse Esophageal Spasm?

Answer 8

1-Barium study show a “corkscrew”’ pattern at time of spasm.

2-most accurate test for diagnosis is a manometric study.

Question 9

what is the Treatment of diffuse esophageal spasm?

Answer 9

calcium-channel blocker e.g., nifedipine, or nitrate.

Question 10

what does Schatzki’s ring leads to?

Answer 10

intermittent dysphagia not associated with pain

Question 11

Schatzki’s ring located at

Answer 11

It is more distal at the squamocolumnar junction proximal to the LES.

Question 12

Plummer-Vinson syndrome (PVS) is located at

Answer 12

more proximal and located in hypopharynx

Question 13

PVS is associated with

Answer 13

1-iron-deficiency anemia and squamous cell cancer

2-in middle-aged women.

Question 14

what is the diagnosis of Schatzki’s ring and Plummer-Vinson syndrome?

Answer 14

barium swallow or barium esophagoram.

Question 15

Treatment of Schatzki’s ring and Plummer-Vinson syndrome

Answer 15

1-treated with dilation procedures.

2-PVS may respond to treatment for iron deficiency

Question 16

Esophagitis is due to

Answer 16

infection or inflammation of the esophagus

Question 17

The most common infection of Esophagitis is

Answer 17

Candida albicans.

Question 18

Candida esophagitis occurs in patients who are

Answer 18

HIV-positive with CD4 count <200/mm3

Question 19

The second most common risk for developing Candida esophagitis is

Answer 19

diabetes mellitus

Question 20

Clinical Presentation of esophagitis

Answer 20

1-Candida esophagitis presents with progressive odynophagia
2-swallowing is painful
3-pain in esophagitis is only on swallowing, while the pain in spastic disorders is intermittent without even needing to swallow.
5-Esophagitis pain is from mechanical rubbing of food against an inflamed
esophagus as it passes by.

Question 21

Treatment of Esophagitis

Answer 21

1-If the patient is HIV-positive, assume Candida esophagitis and start fluconazole
2-If symptoms do not improve, perform
endoscopy and biopsy to exclude other causes such as HSV and CMV

Question 22

the treatment for Candida must be

Answer 22

fluconazole

Question 23

Diagnosis of patients with Candida esophagitis

Answer 23

35% will not have oral thrush

Question 24

esophagitis can also result from

Answer 24

ingestion of medication and caustic substances, the direct effect of contact between the mucosa and the pill causes inflammation rather than infection.

Question 25

The most common pills causing esophagitis are

Answer 25

1-alendronate, 
2-quinine, 
3-risedronate,
4- vitamin C,
5-potassium chloride, 
6-doxycycline, 
7-NSAIDs, and iron sulfate.

Question 26

Consider pill esophagitis in a young patient who takes……… and who has an……….

Answer 26

acne medication

acute onset of odynophagia

Question 27

Pill esophagitis is prevented by

Answer 27

swallowing pills in the upright position and drinking enough water to flush them into the stomach

Question 28

Clinical Presentation of Eosinophilic Esophagitis

Answer 28

1-infiltration with eosinophils
2- no improvement after an
8-week trial of PPIs
GERD can mimic EE

Question 29

Treatment of Eosinophilic Esophagitis

Answer 29

1-fluticasone or budesonide
2-If the biopsy shows eosinophils,
give PPIs before swallowed steroids.

Question 30

define Zenker diverticulum

Answer 30

outpocketing of the posterior pharyngeal constrictor muscles at the back of the pharynx

Question 31

Clinical Presentation of Zenker diverticulum

Answer 31

1-older patients.
2-Bad breath
3-Difficulty initiating swallowing (due to such a proximal lesion)
4-repeatedly clear the throat
5-Waking up with undigested, regurgitated food on the pillow (food from perhaps several days ago)

Question 32

Treatment of Zenker diverticulum

Answer 32

1-surgical resection

2-Endoscopy and the placement of NGtubes are contraindicated because they could perforate the pharynx.

Question 33

define Mallory-Weiss syndrome

Answer 33

nontransmural tear of the lower esophagus that is related to repeated episodes of retching and vomiting.

Question 34

Clinical Presentation of Mallory-Weiss Syndrom

Answer 34

1-No dysphagia or odynophagia, but rather, painless upper GI bleed
2-Black stool from melena if volume of bleed >100 mL or with hematemesis if there is continued vomiting

Question 35

Diagnosis of Mallory-Weiss Syndrom

Answer 35

direct visualization on upper endoscopy

Question 36

Treatment of Mallory-Weiss Syndrome

Answer 36

1-will resolve spontaneously

2-inject the tear with epinephrine or perform cauterization

Question 37

causes of epigastric pain

Answer 37

1-Pancreatitis (most common reason for epigastric tenderness and pain)
2-Ulcer disease (associated with epigastric tenderness in <20% of patients
3-GERD
4-Gastritis
5-Gastric cancer (rare)

Question 38

Helicobacter pylori is most strongly associated with the development of

Answer 38

duodenal ulcers, gastric ulcers, and gastritis.

Question 39

define nonulcer dyspepsia

Answer 39

a functional disorder in which there is persistent pain in the epigastric area but all tests are found to be normal.

Question 40

patients with dyspepsia and alarm features require

Answer 40

upper endoscopy

Question 41

Alarm features for patients with EPIGASTRIC PAIN

Answer 41

• Onset age >50
• Anemia
• Dysphagia
• Odynophagia
• Vomiting
• Weight loss
• Family history of upper GI malignancy
• Personal history of peptic ulcer disease
• Gastric surgery
• GI malignancy
• Abdominal mass or lymphadenopathy on examination

Question 42

Treatment of epigastric pain

Answer 42

1-Treat young, generally healthy patients empirically with H2 blocker, liquid antacid, or PPI; if no improvement, undergo endoscopy.
2-For patients without duodenal/gastric ulcer or gastritis, do not treat for H. pylori.

Question 43

Gastroesophageal reflux disease (GERD) is caused by

Answer 43

abnormal flow of the acid gastric contents backward from the stomach up into the esophagus.

Question 44

number of factors can cause decreased tone or loosening of LES are

Answer 44

• Nicotine, alcohol, caffeine
• Peppermint, chocolate
• Anticholinergics
• Calcium-channel blockers
• Nitrates

Question 45

Clinical Presentation of GERD

Answer 45

1-heartburn (burning substernal pain)
2-sore throat
3-metal-like taste in the mouth
4-hoarseness 
5-cough
6- wheezing.
7-Symptoms are worse after a meal or while lying flat

Question 46

The most accurate diagnostic test for Gastroesophageal Reflux Disease is

Answer 46

1-24-hour pH monitor, an electrode is placed several
centimeters above the gastroesophageal junction, and a determination is made of what the
average pH is in that area.

Question 47

What is the order when working up GERD

Answer 47

• Initiate PPI; if no improvement, increase PPI to 2x daily (before EGD) for 4–8 weeks and make sure patient is taking properly (30–60 min before meals)
• If no improvement, do EGD: If EGD shows esophagitis, that confirms GERD and 24-hour pH monitoring is not needed. If EGD is normal, do ambulatory 24-hour pH monitoring (while off the PPI) and if results are consistent with GERD, do Nissen
fundoplication.

Question 48

In clear cases of epigastric pain going under the sternum and associated with a respiratory
complaint or bad taste in the mouth, do the following

Answer 48

initiate therapy immediately with antisecretory medications such as PPIs.

Question 49

Treatment of GERD is

Answer 49

1- Treatment is a PPI and lifestyle modification (avoid nicotine/alcohol/caffeine/
chocolate/late-night meals
2- elevate the head of the bed 6–8 inches with blocks to keep acid in the stomach)
3-Omeprazole,
4-PPI side effects include increased risk for C. difficile infection, aspiration pneumonia, osteoporosis, and hip fracture
5-A few people (<5%) will not respond to PPIs or will have refractory side effects (headaches, diarrhea); those patients will require surgery to tighten the sphincter (traditionally, a Nissen fundoplication is done laparoscopically).
6-Do motility studies prior to surgery to avoid iatrogenic dysphagia.
7-Use H2 blockers only if the patient has very mild, intermittent symptoms, as they are less effective than PPIs.

Question 50

define Barrett Esophagus

Answer 50

1-a complication of long-standing reflux disease
2-epithelium of the lower esophagus undergoes histologic change from a normal squamous epithelium to a columnar epithelium.

Question 51

Patients with Barrett esophagus should have

Answer 51

repeat endoscopy every 3–5 years to see whether
dysplasia or esophageal cancer has developed:
• If low-grade dysplasia, repeat endoscopy in 6–12 months
• If high-grade dysplasia, do radiofrequency ablation, photodynamic therapy, or
endoscopic mucosal resection
• The usual rate of progression to cancer is about 0.5% per year.

Question 52

Treatment of Barrett esophagus

Answer 52

PPIs