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Esophagus > Anatomy and Physiology of Esophagus > Flashcards

Anatomy and Physiology of Esophagus Flashcards

1
Q

During swallowing the UES moves upwards approximately

A. 0.5cm
B. 1 cm
C. 1.5 cm
D. 2 cm

A

Ans B - 1cm

Shackleford 8e Pg 2

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2
Q

Which of the following does not provide innervation to the UES?

A. IX cranial nerve
B. X cranial nerve
C. XI cranial nerve
D. XII cranial nerve

A

Ans C - XI cranial nerve.

the innervation to the UES is mainly provided by the vagus and to lesser extent by XI and XII cranial nerve.

Shackleford 8e Pg 2.

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3
Q

which of the following is not one of the 3 main phases of swallowing?

A. Oral
B. Pharyngeal
C. Hypopharyngeal
D. Esophageal

A

Ans - C - Hypopharyngeal.

Depending on the author esophageal swallowing can be described in 3-6 different phases.
Three main phases are often differentiated as oral, pharyngeal and esophageal.

Shackleford 8e Pg 2

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4
Q

Which of the following is not involved in the first step of the bolus formation during swallowing?

A. Soft palate
B. Posterior aspect of tongue
C. Hard Palate
D. None of the above

A

Ans C - Hard palate

in the oral phase, the tongue, the soft palate and hard palate and closed glossopalatal area form a bolus.
The first step of bolus formation is performed by soft palate and posterior aspect of the tongue. The second component of the oral phase is the upward movement of the soft palate towards the hard palate, closing the nasopharynx and the upward swing of the hyoid bone more ventrally.

Shackleford 8e Pg 2

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5
Q

which of the following is voluntarily performed during swallowing

A. Oral phase
B. Pharyngeal Phase
C. Esophageal Phase
D. None of the above

A

Ans A - oral phase is voluntary.

Shackleford 8e Pg 2

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6
Q

the most important part of the swallowing process is ?

A. upward movement of the soft palate closing the nasopharynx
B. bolus propelled through the glossopalatal area thus representing the transition from the voluntary oral to the involuntary pharyngeal phase
C. well coordinated closure of the airway during the passage of the bolus
D. movement of the bolus across the UES

A

Ans C -

In health the most important part of the swallowing process is the well coordinated closure of the airway during the passage of the bolus.

Nasopharyngeal area is closed by the soft palate and posterior pharyngeal wall. The muscles of the floor of the mouth pull the hyoid bone and subsequently the larynx and cricoid anteriorly and upward, thus allowing the epiglottis to flip downward and close off the airways.

Shackleford 8e Pg 2

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7
Q

during the swallowing process the UES is relaxed for an average of

A. 0.5s
B. 1s
C. 1.5s
D. 2s

A

Ans B - 1s

Shackleford 8e Pg 2.

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8
Q

Average length of the esophagus in an adult is?

A. 40cm
B. 15cm
C. 20cm
D. 25cm

A

Ans D - 25cm.

Esophageal length is anatomically defined as the distance between the cricoid cartilage (C6) and the gastric orifice (T11)
Ranges from 22 to 28cm. (24cm +/- 5 cm)

Shackleford 7e Pg 10.

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9
Q

what length of the esophagus is usually present in the abdomen

A. 0-2cm
B. 2-4cm
D. 3-6 cm
E. 5-7cm

A

Ans C - 3-6cm

Shackleford 7e Pg 10.

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10
Q

which of the following is not a deviation along the esophagus?

A. base of the neck to the left
B. at level of T7 to the right
C. in front of the sixth cervical vertebra to the left
D. at the EGJ to the left

A

Ans C - in front of the 6th cervical vertebra - this is the level at which the esophagus begins.

Base of the neck to the left - 1st minor deviation
At the level of the 7th thoracic vertebra to the right - 2nd minor deviation
At the EGJ - to the left - 3rd minor deviation.

Shackleford 7e Pg9

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11
Q

Siewert divided the esophagus based on the lymphatic flow with the transition point at ?

A. Arch of aorta
B. Tracheal Bifurcation
C. T8
D. Thoracic inlet

A

Ans B - tracheal bifurcation - is the partition line between lymphatic flow toward caudad and cephalad.

Shackleford 7e Pg 9

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12
Q 
Thoracic duct crosses the esophagus at? 
A. From left to right at level of T6
B. From right to left at level of T6
C. From left to right at level of T5
D. From right to left at level of T5
A

Ans D - from right to left at the level of T4-T5.

Shackleford 7e Pg 9

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13
Q

The esophageal hiatus of the diaphragm lies at the level of

A. T7
B. T8
C. T9
D. T10

A

Ans D - T10

Shackleford 7e Pg 9

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14
Q

which of the following has the narrowest diameter in GIT

A. Cricopharyngeal constriction at UES
B. GEJ
C. Sigmoid Colon
D. Anal canal

A

Ans A - Cricopharyngeal constriction at the UES is the narrowest part of the GIT, with a diameter of 1.5cm, whereas the overall diameter of the esophagus is 2.5cm.

The esophagus is flattened in the cervical and abdominal parts due to the surrounding structures and positive intra-abdominal pressure, whereas it is more rounded in the thoracic part.

Shackleford 8e Pg 31.

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15
Q

Diameter of the lower esophagus is ?

A. 1.6cm
B. 2.0cm
C. 2.5cm
D. 3cm

A

Ans C - 2.5 cm

at rest the esophagus is collapsed, it forms a soft muscular tube that is flat in its upper and middle parts presenting a diameter between 1.6cm and 2.5cm.
The lower esophagus is rounded and has a diameter of 2.5 to 2.4cm.

Shackleford 7e Pg 10.

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16
Q

which of the following is not a supporting structure to the esophagus?

A. Gastrosplenic ligament
B. Phrenicogastric ligament
C. Phrenicoleinal liagement
D. Phrenicocolic ligament

A

Ans D - phrenicocolic ligament

upper end of the esophagus obtains firm anchorage by the insertion of its longitudinal muscles into the cartilaginous structures of hypopharynx by the cricoesophageal tendon.

the circular muscles of the esophagus are stabilized by their continuity with the inferior laryngeal constrictor muscles, which insert into the sphenoid bone.

Tiny membranes connect the esophagus with the trachea, bronchi, pleura and prevertebral fascia.

The lower end attached to the Phreno-esophageal membranes (Mobile) and gastrosplenic, phrenicogastric and phrenicoleinal ligaments and lesser ommentum (Tight).

Shackleford 7e Pg 13.

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17
Q

during swallowing the esophagus may move in vertical direction for a length of approximately?

A. 1 vertebral body
B. 1 cm
C. 1 inch
D. 1 mm

A

Ans A - 1 vertebral body

swallows may result in excursion over as much as the height of one vertebral body.

Shackleford 7e Pg 15.

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18
Q

which of the following statements is false?

A. Pretracheal space is limited distally by the strong fibrous tissue of the pericardium
B. Most of the instrumental perforation during UGIE lead to flow of contents in the pretracheal space
C. The prevertebral space extends from the base of the skull to the diaphragm
D. prevertebral space is formed by the Buccopharyngeal fascia spreading downwards via a sheath that separates the esophageal tissue from the prevertebral fascia.

A

Ans B - most of the instrumental perforations during UGIE lead to flow of contents into the prevertebral space and not the pretracheal space.

Shackleford 7e Pg 15.

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19
Q

Morgagni Hernia is more commonly seen on -

A. Right Posterolateral aspect
B. RIght Anteromedial Aspect
C. Left Posterolateral aspect
D. Left Anteromedial aspect

A

Ans C - Right Anteromedial aspect.

Morgagni Hernia is more common on the Right Anteromedial aspect, whereas the Bochdalek hernia is more common on the left posterolateral aspect.

Shackleford 7e Pg 16.

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20
Q

which of the following is not true regarding the undulating membranes around the esophagus

A. they measure 170 micrometer in thickness
B. they measure 1-2mm in length
C. connect esophagus to the trachea and surrounding tissue
D. consist of collagen, elastic fiber elements and sparse muscle fibers.
E. Stretchable to some extent and accumulate around the tracheal bifurcation

A

Ans B -

the undulating membranes measure 3-5mm in length approximately.

Shackleford 7e Pg 15.

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21
Q

which of the following does not anchor the lower end of the esophagus?

A. Allison membrane
B. Laimer Ligament
C. Phrenoesophageal membrane
D. None of the above

A

Ans D - none of the above.

Allison membrane = Laimer Ligament = PEM

Shackleford 7e Pg 16.

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22
Q

which of the following is not true regarding PEM ?

A. Identified by its yellow color even in severe peri-esophagitis.
B. composed of collagen and elastic fibers.
C. formed by blending of the Sub-diaphragmatic and Endothoracic aproneuroses
D. Inserts on the esophageal musculature.

A

Ans D -

PEM splits into two sheets. In the adult human one sheet extends 2-4cm upwards through the hiatus, where its fibers traverse the esophageal musculature to insert into the submucosa.

Other sheet passes across the cardia upto the level of the gastric fundus where it blends into the gastric serosa, the gastrohepatic ligament and dorsal gastric mesentry.

With advancing age the elastic fibers are replaced by collagenous tissue, and the adhesion of the PEM to the lower esophagus loosens, which leads to loss of pliability

Shackleford 7e Pg 16, 18.

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23
Q

which of the following statements is false?

A. the cricopharyngeus muscle is the UES and composed of striated muscle fibers entirely
B. the first smooth muscle fibers appear 2-3mm caudal to the UES.
C. Caudal to the tracheal bifurcation no striated muscle fibers are present.
D. none of the above

A

Ans D - none of the above.

Shackleford 7e Pg 18.

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24
Q

the manometric length of the UES is ?

A. 0-2cm
B. 2-4cm
C. 4-6cm
D. 6-8cm

A

Ans B - 2-4cm

UES is manometrically a 2-4 cm long zone of elevated pressure. Marks the entrance into the esophagus.
High pressure results from the contraction of the cricopharyngeus muscle.

the cricopharyngeus muscle originates from the lateral cricoid process and closes the esophageal opening by exerting pressure toward the posterior plane of the cricoid cartilage.

Shackleford 7e Pg 20.

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25
Q

the LES is best demonstrated with ?

A. Esophageal manometry
B. Endoscopy
C. Barium Swallow
D. Intraoperative during laparotomy

A

Ans A - Esophageal manometry

the LES is best demonstrated and assessed quantitatively with esophageal manometry.
It can be roughly visualised by endoscopy and radiographic studies.
It cannot be identified from inside the abdomen as a visible anatomic area at the lower end of the esophagus because there is no muscular thickening or special identifiable muscular structure.

Shackleford 8e Pg 4.

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26
Q

which of the following is false regarding LES ?

A. Semicircular muscular clasps are present toward the lesser curvature side at the GEJ
B. Gastric sling fibers form the lower end of the LES towards the left side.
C. LES is a symmetric structural and functional high pressure zone
D. Vagal branches regulate the neurologic function of LES
E. myotomy during achalasia should be performed between the sling fibers and clasps so as to maintain the integrity of the sphincter.

A

Ans C -
LES is an asymmetric structural and functional high pressure zone.

Shackleford 8e Pg 5.

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27
Q

which of the following is not one of the manometrically assessed components of the LES?

A. Overall length of the high pressure zone
B. Sphincter Pressure
C. Sphincter position or Intra-abdominal length of the high pressure zone
D. Diaphragmatic crural component

A

Ans D - diaphragmatic crural component.

Following the DeMeester School the LES can be characterized by 3 manometrically assessed components -
the overall length of the high pressure zone
the sphincter pressure
sphincter position - expressed by the intra-abdominal length of the high pressure zone.

Shackleford 8e Pg 6

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28
Q

the average length of the LES high pressure zone measured manometrically is ?

A. 0-1cm
B. 0-2cm
C. 2-4cm
D. 3-5cm

A

Ans D - 3-5cm

Shackleford 8e Pg 6.

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29
Q

The mean pressure of the LES high pressure zone is?

A. 10 mmHg
B. 14 mmHg
C. 18 mmHg
D. 26 mmHg

A

Ans B - mean pressure of the LES high pressure zone is 14 mmHg.

Shackleford 8e Pg 6.

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30
Q

Which of the following statements is false regarding the LES?

A. Shorter the overall length of the high pressure zone, higher must be the pressure to maintain barrier function

B. A critical component is the intra-abdominal length of LES exposed to the positive intra-abdominal pressure.

C. as GERD develops increasing deficiencies in the overall length, intra-abdominal length and pressure can be seen.

D. none of the above

A

Ans D - None of the above.

Shackleford 8e Pg 6.

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31
Q

what is the number of recording sites in the current HRM technology

A. 31 sites 1cm apart
B. 31 sites 0.5cm apart
C. 36 sites 1cm apart
D. 36 sites 0.5cm apart

A

Ans C - 36 sites 1 cm apart.

Shackleford 8e Pg 7.

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32
Q

most common complaint in patients with esophageal motility disorders

A. Dysphagia related to liquids
B. Dysphagia related to solids
C. Dysphagia related to liquids and solids
D. Reflux

A

Ans C - Dysphagia related to liquids and solids is the most common complaint in patients with esophageal motility disorders. Shackleford 8e Pg 8.

33
Q

which of the following is not true regarding the SCJ at the lower end of esophagus

A. transition between the smooth mucosa of the esophagus and the mammillated dark mucosa of the stomach

B. SCJ is a serrated, but clearly abrupt demarcation line called the Z line.

C. SCJ is the corresponds with the lower end of LES.

D. Z line normally is located immediately above the gastric orifice and marked by the appearance of gastric folds

A

Ans C - The Z line is the mucosal junction wherever it is positioned within the esophagus and it is limited to the mucosa. By no means should the mucosal junction be considered or named a sphincter.

Shackleford 7e Pg 22.

34
Q

Esophagus is lined by -

A. Keratinizing squamous epithelium
B. non-keratinizing simple squamous epithelium
C. Non-keratinizing stratified squamous epithelium
D. non-keratinizing psuedostratified squamous epithelium

A

Ans C -

inner lining of non-keratinizing stratified squamous epithelium.

Shackleford 7e Pg 22.

35
Q

Which of the following is False regarding Muscularis mucosae

A. forms the long mucosal folds that run in the longtiduinal axis
B. forms the small transverse ripple folds at the cardia
C. All these folds can be easily seen throughout endoscopy
D. None of the above

A

Ans C -

all these folds disappear on distension of the esophageal lumen during endoscopic examination.

Shackelford 7e Pg 22.

36
Q

which of the following is TRUE regarding the arterial supply of the esophagus

A. in the neck, superior and inferior thyroid arteries supply cervical esophagus

B. 3-5 tracheobronchial arteries arise at the level of the aortic arch from the convexity of the aortic arch.

C. Proper esophageal arteries arise from the lateral surface of the thoracic aorta.

D. Short Gastric artery gives upto 11 branches to the lower esophagus

A

Ans A -

In the neck, the upper superior and inferior thyroid arteries send small descending arteries to the cervical esophagus.

At the level of the aortic arch, a group of 3-5 tracheobronchial arteries arise from the CONCAVITY of the arch and give rise to several tracheoesophageal tributaries.

Small proper esophageal arteries may arise from the ANTERIOR wall of the thoracic aorta via a larger bronchial artery.

At the cardia the LEFT gastric artery gives off upto 11 branches that ascend and supply the anterior and right side of the lower end of the esophagus.

Several vessels arising from the splenic artery supply the esophageal wall and parts of the greater curvature from the posterior aspect.

Previous claims that essential nutritional vessels supporting the esophagus arising from the phrenic or intercostal arteries could not be confirmed.

Shackelford 7e Pg 23.

37
Q

Which of the following statements is not true regarding the venous drainage of the esophagus?

A. Two large venous plexuses are present in the hypopharynx beneath the mucosa.
B. Hypopharyngeal plexuses are nearly 2-3cm broad and 4cm long.
C. Hypopharyngeal plexuses drain into the thyroid and jugular veins.
D. Account for the ‘globus sensation’ in patients with venou stasis and tissue swelling.
E. None of the above.

A

Ans E - none of the above.

Shackleford 7e Pg 23, 24.

38
Q

Which of the following statements is true about the venous drainage of esophagus?

A. Esophageal venous circulatory system is a valved venous system.

B. The palisade zone in the terminal esophagus contains anastomosis between the hemizygous and portal systems

C. The palisade zone acts as high resistance watershed region with bidirectional flow

D. Anastomoses between the systemic and portal circulation are found in the muscularis mucosae and Lamina propria.

A

Ans C

A - esophageal venous circulatory system is valveless.

B - the palisade zone in the terminal esophagus contains anastomosis between the azygous and portal veins.

D - Anastomoses are found in submucosa and Lamina Propria.

Shackleford 7e Pg 24.

39
Q

_________ vein becomes involved early in midesophageal tumors and is likely cause of fatal hemorrhage during blunt stripping of the esophagus?

A. Hemizygous
B. Azygous
C. Bronchial
D. coronary

A

ans B - Azygous vein

the azygous vein is one of the initial structures to become involved by extramural spread of tumors of the midesophagus, and may be injured easily during esophageal resection. In particular, during blunt pullthrough stripping, injury to this vein is a high risk factor for fatal hemorrhage.

Shackleford 7e Pg 24.

40
Q

arrange the following in the correct order from top to bottom in esophageal venous drainage -

  1. Palisade Zone 2. Gastric zone
  2. truncal zone 4. perforating zone

A. 1,2,3,4
B. 2,3,1,4
C. 4,2,3,1
D. 3,4,1,2

A

Ans D - 3,4,1,2

Shackelford 7e Pg 25.

41
Q

esophageal extrinsic veins do not drain directly into which of following?

A. Left and Right Internal Jugular vein
B. Superior and inferior thyroid
C. Gastric vein and Splenic vein
D. Azygous and hemizygous

A

Ans A - Right and Left IJV.

Shackeford 7e Pg 24.

42
Q

intramural cancer spread occurs mainly through which layer of esophagus

A. Mucosa
B. Lamina Propria
C. Submucosa
D. Muscularis propria

A

Ans C - Submucosa

the paucity of lymphatics found within the submucosa and abundance of submucosal lymphatic channels may explain why intramural cancer spreads predominantly within the submucous layer.

Shackleford 7e Pg 25.

43
Q

which of the following statements is not true?

A. Esophageal lymphatic collecting trunks in the subadventitia are valved
B. Malignant mucosal lesions may be associated with extensive tumor spread underneath an intact mucosa for considerable distance
C. Tumor spread occurs along the transverse axis of the esophagus
D. Tumor free margin at resection line can still have recurrence due to satellite tumors in the submucosa distant from the primary

A

Ans C - spread occurs along the longitudinal axis and not the transverse axis.

Shackleford 7e Pg 26, 27.

44
Q

Which of the following is not true regarding the thoracic duct?

A. starts from cisterna chyli at the level of 12th Thoracic vertebra
B. passes through the diaphragm through the aortic hiatus
C. crosses the esophagus at the level of 5th thoracic vertebra just cranial to the arch of aorta
D. terminates into the confluence of left subclavian and left internal jugular vein

A

Ans C -

the thoracic duct cross the esophagus from right to left at the level of the 5th thoracic vertebra just cranial to the arch of the azygous vein and not the arc of the aorta.

Shackleford 7e Pg 28.

45
Q

which of the following is not true regarding the nerve supply to esophagus?

A. Dorsal vagal nucleus supplies most of the parasympathetic supply to the esophagus

B. Nucleus ambiguus supplies the striated muscles of pharynx and esophagus

C. RLNs give off 8-14 branches for the esophagus which are 5mm-1cm long.

D. Vagus is a purely motor nerve while the sensory signals are carried by the sympathetic system.

A

Ans D -

vagus is a mixed nerve. Also carries sensory fibers from the superior ganglion and inferior ganglion (Nodose ganglion)

Shackleford 7e Pg 29.

46
Q

HRM is done using ?

A. 10 swallows of 5mL each
B. 5 swallows of 10mL each
C. 10 swallows of 10 mL each
D. 5 swallows of 5mL each

A

Ans - A

HRM is based on ten 5 mL water swallows performed in supine position. During each swallow the following features are evaluated -

EGJ relaxation
Esophageal contractile activity
Esophageal pressurization

Shackleford 8e Pg 11.

47
Q

Which of the following is not a topographic measurement used in HRM?

A. Integrated relaxation potential
B. Distal Contractile Integral
C. Contractile decelaration point
D. Distal Latency
E. None of the above
A

Ans E - none of the above.

IRP, DCI, CDP and DL are the 4 main topographic measurements in HRM.

Shackleford 8e Pg 11.

48
Q

Which of the following is TRUE regarding IRP ?

A. mean of 5s of maximal deglutitive relaxation
B. it can be any 5s in a window of 12s starting from deglutitve UES relaxation
C. best metric to differentiate between normal and impaired EGJ relaxation
D. Not influenced by Crural Diaphragm contraction and intrabolus pressure

A

Ans C - IRP is the best metric to differentiate between normal and impaired relaxation.

During swallowing the pressure detect at the level of EGJ is defined by the LES pressure, contraction of the crural diaphragm and intrabolus pressure as the swallowed bolus passes through the EGJ.

IRP defined as the mean pressure for the 4s of maximal deglutitive relaxation in the 10s window starting with the deglutitive relaxation of the UES relaxation and it is the best metric to differentiate between normal and impaired EGJ relaxation.

IRP is influenced not only by LES relaxation but also by CD contraction and intrabolus pressure.

Normal values depend on the HRM device used with upper limit values ranging from 15mmHg to 28 mmHg depending on the transducer.

Shackleford 8e Pg 11.

49
Q

which of the following is type IIIa of EGJ based on axial relationship between LES and CD from HRM studies?

A. separation between LES and CD >2cm and the pressure inversion point remains at the level of CD.

B. Separation between LES and CD >2cm and the pressure inversion point is localised at the level of LES

C. LES and CD are completely overlapped

D. LES and CD are separated with separation <2cm

A

Ans A -

Type I - LES and CD are completely overlapped
Type II - LES and CD are separated but separation is less than 2cm.
Type III - LES and CD are separated but the separation is more than 2cm
IIIa - the pressure inversion point remains at the level of CD
IIIb - the pressure inversion point is localized at the level of LES.

Shackleford 8e Pg 11

50
Q

the wave of primary peristalsis in esophagus travels at ?

A. 0-2 cm/s
B. 2-3 cm/s
C. 3-4 cm/s
D. 4-6 cm/s

A

Ans C - 3-4 cm/s

Shackleford 8e Pg 11.

51
Q

The wave of primary peristalsis in esophagus typically reaches a pressure of _________ in distal esophagus.

A. 40-80 mmHg
B. 60-140 mmHg
C. 100-150 mmHg
D. 120-200 mmHg

A

Ans B - 60-140 mmHg

Shackleford 8e Pg 11.

52
Q

Local stimulation by distension at any point in the body of the esophagus will elicit a peristaltic wave from the point of stimulus. This is known as ?

A. Primary Peristalsis
B. Secondary Peristalsis
C. Tertiary Peristalsis
D. Quarternary Peristalsis

A

Ans B - secondary peristalsis.

Secondary peristalsis aids the esophageal emptying when the primary wave has failed to clear the lumen of ingested food, or when gastric contents reflux from the stomach.

Shackleford 8e Pg 11.

53
Q

which of the following is not considered normal?

A. Primary peristalsis
B. secondary peristalsis
C. tertiary peristalsis
D. None of the above

A

Ans C -

Tertiary waves are considered abnormal, but they are frequently seen in elderly patients who have no symptoms of esophageal disease.

Shackleford 8e Pg 11.

54
Q

premature contraction is defined as a CDP of less than ?

A. 2s
B. 3s
C. 4s
D. 4.5s

A

ans D 4.5 s

Distal Latency or DL represents the interval between UES relaxation and the Contractile decelaration point. It is considered an important metric indicating the integrity of the inhibitory pathway in the distal esophagus.
A value less than 4.5s defines premature contraction, indicative of spasm.

Shackleford 8e Pg 11.

55
Q

Normal value of DCI ranges from ?

A. 200-400 mmHg-s-cm
B. 450-800 mmHg-s-cm
C. 450-8000 mmHg-s-cm
D. 450-800 mmHg-s-m

A

ans C - 450-8000 mmHg-s-cm

DCI describes the vigor of the distal esophageal contraction. It is measured as the volume of the esophageal contraction spanning from the transition zone to the EGJ.
Product of the integral of the amplitude exceeding 20mmHg, the duration and the length of the contractile segment between the transition zone and EGJ.
Therefore the unit of DCI is mmHg.s.cm

DCI in normal subjects ranges from 450-8000 mmHg.s.cm

Shackleford 8e Pg 11.

56
Q

DCI ranging from 100-450 mmHg.s.cm is

A. failed peristalsis
B. weak peristalsis
C. normal peristalsis
D. hypercontractile peristalsis

A

Ans B - weak peristalsis.

Hypercontractility >8000 mmHg.s.cm
Weak peristalsis 100-450 mmHg.s.cm
Normal peristalsis 450-8000 mmHg.s.cm
Failed Peristalsis <100 mmHg.s.cm

Both failed and weak contractions are considered ineffective.
Shackleford 8e Pg 11.

57
Q

Intrabolus pressure pattern on HRM is assessed using the

A. 10 mmHg isobaric contour
B. 20 mmHg isobaric contour
C. 30 mmHg isobaric contour
D. 40 mmHg isobaric contour

A

Ans C - 30 mmHg isobaric contour.

Intrabolus pressure is qualified as panesophageal pressurization if it spans from UES to EGJ.

Intrabolus pressure is qualified as compartmentalized pressurisation if it is restricted to the segment between the deglutitive contractile front and the EGJ.

Shackleford 8e Pg 11.

58
Q

Contraction integrity on HRM is defined using the

A. 10mmHg isobaric contour
B. 20mmHg isobaric contour
C. 30 mmHg isobaric contour
D. 40 mmHg isobaric contour

A

Ans B - 20 mmHg isobaric contour.

Small interruptions or breaks (2-5cm in length) in the 20 mmHg isobaric contour between the UES and EGJ are considered normal, whereas large breaks (>5cm in length) define weak contractions.
Shackleford 8e pg 12.

59
Q

EGJ outflow obstruction is defined by

A. mean IRP >5mmHg
B. median IRP >10 mmHg
C. mean IRP >15 mmHg
D. median IRP >15 mmHg

A

Ans D -median IRP more than 15 mmHg

Shackleford 8e Pg 12.

60
Q

which of the following is criteria for type II achalasia?

A. Median IRP >15mmHg
B. 100% failed peristalsis (DCI <100 mmHg.s.cm)
C. pan-esophageal pressurisation for at least 20% of swallows.
D. all of the above

A

Ans D - all of the above.

Type I - classic achalasia - median IRP >15 mmHg + 100% failed peristalsis (DCI <100 mmHg.s.cm) and no esophageal pressurisation

Type II - with esophageal compression - median IRP >15mmHg + 100% failed peristalsis and panesophageal pressurisation for at least 20% of swallows.

Type III - spastic achalasia - Median IRP >15mmHg, preserved fragments of distal peristalsis or premature contraction (DCI > 450 mmHg.s.cm) for atleast 20% of swallows.

Shackleford 8e Pg 12.

61
Q

best response to pneumatic dilation is seen with

A. Type I achalasia
B. type II achalasia
C. Type III achalasia
D. both a and b

A

Ans B -

type II achalasia had a better response to the endoscopic pneumatic dilation than did type I and III.

Shackleford 8e Pg 13.

62
Q

aperistalsis can be seen in

A. GERD
B. Scleroderma
C. both
D. none

A

Ans C - both GERD and Scleroderma can present with aperistalsis or 100% failed contractions.

Shackleford 8e Pg 13.

63
Q

A patient who underwent HRM was found to have a normal IRP with >20% swallows with premature contractions (DCI > 450 mmHg.s.cm and DL <4.5s). He is suffering from ?

A. EGJ outflow obstruction
B. Achalasia cardia
C. DES
D. Jackhammer esophagus

A

Ans C - DES.

Shackelford 8e Pg 13.

64
Q

which of the following can be a cause of Jackhammer esophagus?

A. GERD
B. EGJ outflow obstruction
C. Eosinophilic esophagitis
D. All of the above

A

Ans D - All of the above.

hypercontractile esophagus is a disorder that might occur as a primary esophageal motility disorder or be present in the context of GERD, EGJ outflow obstruction and Eosinophilic esophagitis.

Shackleford 8e Pg 13.

65
Q

HRM with >20% swallows with DCI > 8000 mmHg.s.cm suggestive of

A. Hypercontractile esophagus
B. Achalasia cardia
C. Nutcracker esophagus
D. Diffuse Esophageal spasm

A

Ans A - Hypercontractile or Jackhammer esophagus.

Shackleford 8e Pg 13.

66
Q

Ineffective esophageal motility HRM criteria is ?

A. Distal esophageal amplitude less than 30 mmHg
B. simultaneous waves in more than 50% of wet swallows
C. more than 50% ineffective swallows with DCI < 450 mmHg.s.cm
D. All of the above

A

Ans C -

Distal esophageal amplitude less than 30 mmHg or simultaneous waves in more than 50% of wet swallows are criteria to diagnose IEM on conventional manometry.
Whereas the HRM criteria is more than 50% ineffective swallows with DCI < 450 mmHg.s.cm.

Shackleford 8e Pg 13.

67
Q

Which of the following is the shortest route of reconstruction after esophagectomy?

A. Posterior Mediastinal (Orthotopic route)
B. Retrosternal route
C. Subcutaneous route
D. All are the same

A

Ans A - Posterior mediastinum or Orthotopic route is 30cm and shortest, Retrosternal route is 32cm and subcutaneous route is 34cm.

Shackleford 8e Pg 31.

68
Q

what is the length of the cervical esophagus?

A. 5cm
B. 4 cm
C. 6cm
D. 7 cm

A

Ans A - 5cm

the cervical esophagus extends from the cricoid cartilage at the C6 to the T1-T2 space.

Shackleford 8e Pg 31

69
Q

incidence of the nonrecurrent RLN on the right side?

A. 0.5%
B. 0.1%
C. 1%
D. 5%

A

Ans B - 0.1% is the incidence of the non-recurrent nerve on the right.

Shackleford 8e Pg 31.

70
Q

best approach to the mid esophagus ?

A. Left thoracotomy
B. Left thoracoscopic
C. Right thoracotomy
D. Transhiatal

A

Ans C - Right thoracotomy

The esophagus passes through the middle mediastinum and shifts to the right at the level of T7, so the best approach to the mid-esophagus is through the right thoracotomy or thoracoscopy.

Shackleford 8e Pg 33.

71
Q

Best approach to the distal thoracic esophagus ?

A. Left thoracotomy
B. Right thoracotomy
C. Transhiatal
D. Right thoracoscopic

A

Ans A - Left thoracotomy or thoracoscopy is the best approach for the distal thoracic esophagus.

Shackleford 8e Pg 33.

72
Q

Boerhaave Perforation occurs most commonly along?

A. Left Lateral aspect
B. Right lateral aspect
C. Anterior aspect
D. Posterior aspect

A

Ans A -

the left lateral distal esophagus is convered only with mediastinal pleura. As a result of the relative weakness in this area, spontaneous Boerhaave perforation occurs most commonly along the left lateral aspect of the distal esophagus.

Shackleford 8e Pg 34.

73
Q

Achalasia results from degeneration in neurons in the

A. Vagus nerve
B. Auerbach Plexus
C. Myenteric Plexus
D. RLN nerve

A

Ans B - Auerbach Plexus.

The submucosal plexus or Meissner plexus regulates the contraction of the muscularis mucosae and secretions.
Achalasia results from the degeneration of the ganglion in Auerbach plexus leading to aperistalsis of esophagus with impaired relaxation of the lower esophageal sphincter.

Shackleford 8e Pg 36.

74
Q

Which of the following is True statement?

A. Anterior vagus is entirely made up of fibers from the left vagus

B. Posteror vagus is entirely made up of fibers from the Right vagus

C. Both vagal trunks contain nerve fibers originating from the left or right vagal nerves.

D. This configuration of the vagus nerves is due to the rotation of the stomach during the embryological period.

A

Ans C -

Anterior fibers from the left vagus coalesce into the anterior vagus, and the posteror fibers from the right vagus coalesce into the posterior vagus, although both vagal trunks can contain nerve fibers originating from the left or right vagal nerves.

Shackleford 8e Pg 36.

75
Q

which of the following structures donot pass through the aortic hiatus?

A. Azygous vein
B. Hemizygous vein
C. Thoracic duct
D. Vagal trunks

A

Ans D - Vagal trunks

the main lymphatic vessel is the thoracic duct, which begins in the abdomen as the cisterna chyli at T12 and passes through the aortic hiatus along with the aorta and the azygous and hemiazygous veins. To perform a mass ligation for a chylothorax, the tissue between the azygous vein and aorta is ligated just above the diaphragm.
The duct turns behind the left mainstem bronchus at level of the T5 or T6.

Shackleford 8e Pg 38.

76
Q

Thoracic duct is damaged in what percentage of esophagectomies?

A. 1%-2%
B. 4-5%
C. 0.1-0.2%
D. 10%

A

Ans A -

the thoracic duct is adjacent to the thoracic esophagus and is damaged in 1-2% of the esophagectomies.

Shackleford 8e Pg 39.

77
Q

EUS-FNA can target all of the following stations except?

A. 2 (Upper paratracheal)
B. 3A (Anterior mediastinal
C. 4 Lower paratracheal
D. 7 Subcarinal
E. 8 Paraesophageal
F. 9 Inferior pulmonary ligament
A

Ans B -

the EUS-FNA can target 3P (Posterior mediastinal) and not anterior.

Shackleford 8e Pg 39.

78
Q

Second most common site of esophageal perforation?

A. above the UES
B. Distal esophagus near the cardia
C. Mid-thoracic esophagus
D. Just above the carina

A

Ans B - Distal esophagus near the cardia is the second most common site of esophageal perforation.

Shackleford 8e Pg 39.

79
Q

Lower Esophageal sphincter usually relaxes _____ seconds after swallowing is initiated.

A. 1s
B. 2s
C. 3s
D. 5s

A

Ans C - 3s

Shackleford 8e Pg 42.

Esophagus (7 decks)

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