GI #5

Question 1

What is achalasia?

Answer 1

-Loss of peristalsis and failure of relaxation of the LES

Question 2

What is the pathophysiology of Achalasia?

Answer 2

Idiopathic degeneration of Auerbach’s plexus leads to increased LES pressure and impaired LES relaxation

Question 3

Symptoms of achalasia

Answer 3

• Dysphagia to both solids and liquids at the same time
• Weight loss
• Malnutrition
• Regurgitation of undigested food

Question 4

What is the MOST accurate diagnostic for achalasia?

Answer 4

Manometry: increased LES pressure and lack of peristalsis

Question 5

What is seen on a barium esophageal for achalasia?

Answer 5

-Bird’s beak appearance of LES (narrowing of LES) with proximal esophageal dilation and loss of peristalsis distally

Question 6

What is performed in a patient with achalasia prior to initiating treatment to rule out esophageal SCC?

Answer 6

Endoscopy

Question 7

How to manage a patient with achalasia?

Answer 7

• Decrease LES pressure: Botulinum toxin, Nitrates, Surgery
• Pneumatic dilation of LES
• Esophagomyomectomy (definitive)

Question 8

What is a Zenker’s Diverticulum?

Answer 8

Pharyngoesophageal pouch (false diverticulum) that only involves the mucosa and possibly submucosa

Question 9

Zenker’s Diverticulum MC occurs in

Answer 9

Males in 70’s

Question 10

What is the pathophysiology of Zenker’s Diverticulum?

Answer 10

Weakness at junction of Killian’s Triangle (between fibers of cricopharyngeal muscle and lower inferior pharyngeal constrictor muscle)

Question 11

Symptoms of a Zenker Diverticulum

Answer 11

• Dysphagia
• Regurgitation of undigested food
• Neck mass
• Choking sensation
• Halitosis (due to food retention in pouch)

Question 12

What is the initial test of choice for a Zenker Diverticulum?

Answer 12

-Barium Esophagram with video fluoroscopy (collection of dye behind esophagus at pharyngoesophageal junction)

Question 13

However, an ________ is usually performed for surgical evaluation for a Zenker

Answer 13

Upper endoscopy

Question 14

Management for a Zenker Diverticulum

Answer 14

Observation if small and asymptomatic

Diverticulectomy if large or symptomatic

Question 15

Explain distal (diffuse) esophageal spasms

Answer 15

-Severe, non-peristaltic esophageal contractions (uncoordinated contractions)

Question 16

Symptoms of diffuse esophageal spasms

Answer 16

• Stabbing, chest pain worse with hot or cold liquids

- Dysphagia to both solids and liquids

Question 17

Definitive diagnostic for diffuse esophageal spasm

Answer 17

Manometry: increased simultaneous or premature contractions

Question 18

What is seen on esophagram with diffuse esophageal spasm

Answer 18

Corkscrew esophagus: severe, non-peristaltic contractions

Question 19

First-line treatment for diffuse esophageal spasms

Answer 19

-Anti-Spasmodics (CCB, Nitrates, TCAs)

Question 20

What are other treatment options for diffuse esophageal spasms?

Answer 20

-Botulinum toxin, Pneumatic dilation

Question 21

What is hyper contractile (jackhammer) esophagus

Answer 21

-Increased pressure during peristalsis

Question 22

What is another name for Jackhammer Esophagus?

Answer 22

-Nutcracker Esophagus

Question 23

Symptoms of jackhammer Esophagus

Answer 23

• Dysphagia to both solids and liquids

- Chest pain, retrosternal

Question 24

Definitive diagnostic for jackhammer esophagus

Answer 24

Manometry: increased pressure during peristalsis

Question 25

What tests are usually normal in jackhammer esophagus?

Answer 25

Upper endoscopy and esophagram

Question 26

Treatment for hyper contractile esophagus

Answer 26

-CCB, Nitrates, Botulinum injection, TCA

Question 27

What is the difference in presentation between diffuse esophageal spasm and hypercontractile esophagus?

Answer 27

- Diffuse: severe, non-peristaltic contractions | - Hypercontractile: increased pressure during peristalsis

Question 28

Boerhaave Syndrome (esophageal perforation) is a

Answer 28

Full thickness rupture most commonly affecting the left posterolateral wall of the lower esophagus

Question 29

What is the MC cause of Boerhaave Syndrome?

Answer 29

-Iatrogenic perforation during endoscopy

Question 30

But other causes of Boerhaave Syndrome include

Answer 30

-Repeated, forceful vomiting (Bulimia, alcoholism)

Question 31

Symptoms of Boerhaave Syndrome

Answer 31

- Chest pain worse with breathing and swallowing - Vomiting - Hematemesis - Crepitus on auscultation - Hamman's Sign: crackling accompanying every heart beat in left lateral decubitus position

Question 32

What is Hamman's Sign?

Answer 32

Crackling associated with every heart beat in left lateral decubitus position

Question 33

What is the diagnostic test of choice for Boerhaave Syndrome?

Answer 33

Contrast esophagram: Gastrografin swallow preferred

Question 34

What does a CXR show in Boerhaave Syndrome?

Answer 34

Pseudomediastinum

Question 35

Treatment for Boerhaave Syndrome?

Answer 35

Small and stable: IVF, NPO, H2 receptor blockers, ABX | Large or severe: surgical repair

Question 36

What is a Mallory-Weiss Syndrome/Tear?

Answer 36

-Longitudinal superficial mucosal laceration at GEJ or gastric cardia

Question 37

What is the cause of a Mallory-Weiss Tear?

Answer 37

Sudden rise in intraabdominal pressure or gastric prolapse into the esophagus (persistent retching or vomiting after ETOH binge)

Question 38

Symptoms of a Mallory-Weiss Tear

Answer 38

- Upper GI bleeding: hematemesis, melena, hematochezia, syncope - Abdominal pain, back pain

Question 39

What is the test of choice for a Mallory-Weiss Tear?

Answer 39

Upper endoscopy: shows superficial longitudinal mucosal erosions

Question 40

Treatment for Mallory-Weiss Tears (not actively bleeding vs severe bleeding)

Answer 40

Not actively bleeding: supportive, acid suppression with PPI Severe bleeding: thermal coagulation, hemoclips, endoscopic band ligation, balloon tamponade