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Gastroenterology USMLE Step 3 > Section 1: Esophageal Disorders & Epigastric Pain > Flashcards

Section 1: Esophageal Disorders & Epigastric Pain Flashcards

1
Q

General presentation of esopgageal disorders

A
  • Dysphagia
  • Weight loss
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2
Q
  • Dysphagia + Unknown diagnosis. What is the initial test
A
  • Barium study
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3
Q

Difference between dysphagia and odonophagia and the implications of both

A

Dysphagia (difficulty swallowing) is different from odynophagia (painful swallowing)

Odynophagia suggests an infectious process, such as HIV, HSV, or Candida.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5674-5675). . Kindle Edition.

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4
Q

Clinical presentation of achalasia

A
  • Young nonsmoker
  • Dysphagia to both solids and liquids at the same time
  • Regurgitation of food particles
  • Aspiration of previously eaten material that is regurgitated and falls into the lungs

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5677-5681). . Kindle Edition.

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5
Q

Achalasia:

  • Best initial test
  • Most accurate test
A
  • Barium swallow
  • Esophageal manometer

Endoscopy is not necessary to diagnose achalasia; it is done to exclude malignancy. Manometry would show absence of normal esophageal peristalsis. Achalasia presents with abnormally high pressure at the lower esophageal sphincter, since it involves a failure of the gastroesophageal sphincter to relax. There is no mucosal abnormality.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5685-5687). . Kindle Edition.

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6
Q

Achalasia:

Best initial Rx

A

** Surgical myotomy**

Pneumatic dilation (if surgical myotomy fails)

Botilinium toxin injection for those who refuse surgery

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7
Q

Clinical presentation of esophageal cancer

A
  • Dysphagia: Solids first, then liquids
  • Heme-positive blood or anemia
  • Usually, >50years
  • Smokers
  • Alcohol use
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8
Q

Diagnosis:

  • Dysphagia + Weight loss
  • Dysphagia + Weight loss + Heme positive stool/anemia
A
  • Esophageal pathology
  • Cancer
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9
Q

Esophageal cancer:

Best initial diagnosis

A

Endoscopy

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10
Q

Rx of esophageal cancer

A

Surgery + 5-fluorouracil based chemotherapy

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11
Q

Best initial test for esophageal ring or web

A

Barium study

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12
Q

Rx of seophageal ring/web

  1. Plummer-Vinson Syndrome
  2. Schatzki’s ring (peptic stricture)
  3. Peptic stricture from acid reflux
A
  1. Iron replacement
  2. Pneumatic dilation
  3. Pneumatic dilation
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13
Q

Clinical features of Zenker’s diverticulum

A
  • Dysphagia
  • Horrible bad breath
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14
Q

Zenker’s diverticulum:

  • Best initial test
  • Best initial Rx
A
  • Barium study
  • Surgical resection

To avoid perforation, do not do endoscopy or place an NG tube with Zenker’s diverticulum

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15
Q

True or False:

Diffuse esophageal spasm = Nutcracker esophagus

A

True

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16
Q
  1. Most accurate test for esophageal spastic dissorders
  2. Rx of esophageal spastic disorders
A
  1. Manometry

Barium study may show cockscrew pattern but only during episode of spasm

  1. CCBs and nitrates
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17
Q

Rx of reflux symptom of scleroderma

A

Proton pump inhibitor

18
Q

An HIV-positive man comes in with progressive dysphagia and odynophagia. He has 75 CD4 cells but no history of opportunistic infections. What is the next best step in management?

a. Fluconazole
b. Amphotericin
c. Barium swallow
d. Endoscopy
e. Antiretroviral therapy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5752-5761). . Kindle Edition.

A

A. Odynophagia is pain on swallowing. Dysphagia is simply difficulty swallowing (i.e., food getting “stuck” in the esophagus). When odynophagia occurs in an HIV-positive patient, particularly when there are < 100 CD4 cells, the diagnosis is most likely esophageal candidiasis, and giving empiric fluconazole is both therapeutic as well as diagnostic. Amphotericin is not necessary.

Esophageal disorders can mimic Prinzmetal’s variant angina, because the pain is sudden, severe, and not related to exercise. However, Prinzmetal’s will give you ST segment elevation and an abnormality on stimulation of the coronary arteries, while esophageal spasm will not.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5761-5766). . Kindle Edition.

19
Q

Diagnostic testing for esophagitis

A
  • HIV-negative patient: Endoscopy is done first
  • HIV-positive patients with CD4 <100, give fluconazole
    • Endoscopy if fluconazole does not work
20
Q

Causes of esophagitis in HIV-positive patients

A

Candida

Doxycycline

Biphosphonate e.g. Alendronate

21
Q

Rx of Mallory-Weiss tear

A
  • Most resolve spontaneously
  • Injection epinephrine if bleeding persists
22
Q

A patient comes with epigastric pain that is associated with substernal chest pain and an unpleasant metallic taste in the mouth. What is the next best step in management?

a. Endoscopy
b. Barium studies
c. Proton pump inhibitors (PPIs)
d. H2 (histamine) blockers
e. 24-hour pH monitor

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5796-5804). . Kindle Edition.

A

Answer: C. Proton pump inhibitors (PPIs) are preferred as the first line of therapy and also serve as a diagnostic test. Using PPIs is far easier than other testing.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5804-5810). . Kindle Edition.

23
Q

In addition to the epigastric pain and substernal chest pain of GERD, several other symptoms are clearly associated with acid reflux. List them.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5804-5810). . Kindle Edition.

A
  • Sore throat
  • Metallic or bitter taste
  • Hoarseness
  • Chronic cough
  • Wheezing
  • As many as 20-25 percent of those with chronic cough are suffering from GERD
  • 25 percent of chronic cough is caused by GERD

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5804-5810). . Kindle Edition.

24
Q

Indications for endoscopy in GERD

A
  • Weight loss
  • Anemia
  • Blood in the stool
  • Dysphagia
25
Rx of mild GERD
* Weight loss * Elevating head of bed * Quitting smoking * Limiting alcohol, caffeine, chocolate, and peppermint ingestion * Not eating within 3 hours of going to sleep
26
State the best course of action after the following endoscopic findings: 1. Barret esophagus 2. Low-grade dysphagia 3. High-grade dysphagia
1. PPI and repeat endoscopy every 2 to 3 years 2. PPI and repeat endoscopy in 3 to 6 months 3. Distal esophagectomy
27
A 58-year-old man comes to the office for evaluation of epigastric discomfort for the last several weeks. He is otherwise asymptomatic with no weight loss. His stool is heme-negative. What is the next best step in management? a. Upper endoscopy b. Serology for Helicobacter pylori c. Urea breath testing for Helicobacter pylori d. PPI, amoxicillin, and clarithromycin for 2 weeks e. Ranitidine empirically Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5862-5873). . Kindle Edition.
**A**. Upper endoscopy should be performed in any patient above the age of 45 with persistent symptoms of epigastric discomfort. This is, essentially, to exclude the possibility of gastric cancer. There is no way to be certain, without endoscopy, who has gastric cancer. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5862-5873). . Kindle Edition.
28
Diagnostics tests for Helicobacter pylori: * Most accurate test * Serology * Breath testing and stool antigen testing
* Endoscopy with biopsy. If this is done, no further testing is necessary for Helicobacter * Very sensitive but not specific. If the serology is negative, this excludes Helicobacter. A positive test cannot distinguish between new and previous infection * These are not standard or routinely used. They can, however, distinguish between new and old disease. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5897-5901). . Kindle Edition.
29
Rx for Helicobacter pylori
* PPI and clarithromycin and amoxicillin. Only treat Helicobacter if it is associated with gastritis or ulcer disease. * If treatment for H. pylori fails, proceed as follows: * 1. Repeat treatment with 2 new antibiotics and a PPI. Try metronidazole and tetracycline instead of clarithromycin and amoxicillin. * 2. If repeat treatment fails, then evaluate for Zollinger-Ellison syndrome (gastrinoma). Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5903-5910). . Kindle Edition.
30
Indications for prophylaxis Rx of stress ulcer
* Head trauma * Intubation and mechanical ventillation * Coagulopathy and steroid use in combination
31
A 52-year-old man has epigastric discomfort. He is seropositive for Helicobacter pylori. Upper endoscopy reveals no gastritis and no ulcer disease. Biopsy of the stomach shows Helicobacter. What should you do? a. Breath testing b. PPI alone as symptomatic therapy c. Repeat endoscopy after 6 weeks of PPIs d. PPI, amoxicillin, and clarithromycin Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5916-5931). . Kindle Edition.
**B**. You do not need to treat Helicobacter pylori unless there is gastritis or ulcer disease. This patient has epigastric pain and Helicobacter but no ulcer or gastritis. This is non-ulcer dyspepsia. Treat it symptomatically with a PPI. Enormous numbers of people are colonized with H. pylori; you do not need to eradicate it from the world without evidence of disease. H. pylori is not the cause of non-ulcer dyspepsia. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5916-5931). . Kindle Edition.
32
A man is found to have ulcer disease. There are 3 ulcers in the distal esophagus 1– 2 cm in size. The ulcers persist despite treatment for Helicobacter. What should you do next? a. Switch antibiotics b. Breath testing c. Gastrin level and gastric acid output d. CT scan of the abdomen e. ERCP Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5928-5945). . Kindle Edition.
**C**. Gastrin level and gastric acid output testing should be done when there is the possibility of Zollinger-Ellison syndrome. ERCP will only show the ducts of the pancreas and gallbladder; it will not reveal gastrinoma. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5928-5945). . Kindle Edition.
33
List the characteristics of most peptic ulcers Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5928-5945). . Kindle Edition.
* Single * \< 1 cm * Proximal near the pylorus * Easily resolve with treatment Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 5928-5945). . Kindle Edition.
34
Diagnosis: * Elevated gastrin level + elevated acid output * Elevated gastrin level
* Zollinger-Ellison syndrome (ZES) * H2 blocker; PPI
35
Indications for testing gastrin level and gastric acid output
* Large ulcer \> 1cm * Multiple ulcers * Distal location near the ligament of Treitz * Recurrent or persistent ulcer(s) despite Rx for Helicobacter pylori If the gastrin and acid output are both elevated, then localization of the gastrinoma is next
36
Most accurate tests for ZES
* Endoscopic ultrasound * Nuclear scolarisation scan
37
Effect of infusing IV secretin on gastrin secretion in: 1. Normal person 2. Patient with ZES
1. Decreases gastrin secretion 2. No change on gastrin secretion
38
Effect of infusing IV secretin on gastrin secretion in: 1. Normal person 2. Patient with ZES
1. Decreases gastrin secretion 2. No change on gastrin secretion
39
Rx of ZES
* Local disease: Surgical resection * Metastati disease: Lifelong PPIs
40
Diagnosis: ZES + Hypercalcemia
Multiple Endocrine Neoplasm (MEN)

Gastroenterology USMLE Step 3 (5 decks)

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