LE3 Esophagus Flashcards

Question

The following chemicals & hormones increase the LES pressure, except: A. Antacids B. Gastrin C. Theophylline D. Beta blockers E. Metoclopramide

Answer 1

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.

Answer 2

C. Peptic Ulcer Disease (PUD)

Answer 3

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.

Answer 4

D. Diverticular perforation

Answer 5

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.

Answer 6

A. Width of diaphragmatic hiatus

Answer 7

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.

Answer 8

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.

Answer 9

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.

Answer 10

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.

Answer 11

A. Esophageal cancer Rationale: Dysphagia and weight loss are hallmark symptoms of esophageal cancer, often occurring due to the tumor obstructing the esophagus.

Answer 12

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.

Answer 13

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.

Answer 14

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.

Answer 15

B. Esophagectomy Rationale: Esophagectomy refers to the surgical removal of the esophagus, often followed by reconstruction using the stomach or part of the intestine.

Answer 16

A. Spontaneous perforation

Answer 17

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.

Answer 18

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.

Answer 19

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.

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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.

Answer 24

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.

Answer 25

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.

Answer 26

D. Acid, pepsin, and bile contents Rationale: Maximal mucosal injury occurs when the esophagus is exposed to a combination of acid, pepsin, and bile. Studies indicate that the combination of these components is highly damaging, with acid alone causing minimal damage. Duodenal contents such as bile, when mixed with gastric acid, significantly increase mucosal injury.

Answer 27

B. 0.2 to 0.5% per year Rationale: Barrett esophagus (BE) is a condition where the normal squamous epithelium of the esophagus is replaced by columnar epithelium due to chronic acid exposure. The risk of BE progressing to adenocarcinoma is estimated to be between 0.2 to 0.5% per year. Regular surveillance is recommended to monitor for dysplasia or malignant transformation.

Answer 28

B. Goblet cells Rationale: The histologic hallmark of Barrett esophagus is the presence of goblet cells in the columnar epithelium, indicative of intestinal metaplasia. These goblet cells are a marker for a higher risk of progression to adenocarcinoma.

Answer 29

C. 50% Rationale: Around 50% of patients with reflux-associated asthma experience relief from respiratory symptoms with medical therapy, such as proton pump inhibitors (PPIs), although improvements in pulmonary function are seen in fewer patients.

Answer 30

C. A 75-year-old man with new onset heartburn not relieved by PPIs Rationale: Patients with new onset symptoms, especially in older individuals, should undergo further diagnostic evaluation before considering surgery. Other options such as medical therapy or addressing the underlying cause may be more appropriate. Antireflux surgery is typically recommended for patients with well-documented gastroesophageal reflux disease (GERD) who have failed medical management or prefer to avoid lifelong medication.

Answer 31

A. Computed tomography (CT) scan of the chest and abdomen Rationale: Preoperative testing for antireflux surgery usually includes a contrast esophagram, 24-hour pH probe, esophageal manometry, and esophagogastroduodenoscopy (EGD) to assess esophageal function and confirm reflux. A CT scan is not routinely required unless there are other complications or concerns.

Answer 32

C. 3 cm Rationale: The length of the reconstructed antireflux valve, whether during a full or partial fundoplication, should be at least 3 cm to ensure adequate pressure augmentation and to prevent gastric contents from refluxing into the esophagus.

Answer 33

D. 80-90% Rationale: Long-term studies show that 80-90% of patients experience relief of typical reflux symptoms (such as heartburn, regurgitation, and dysphagia) 5 years or more after antireflux surgery, including both open and laparoscopic fundoplication procedures.

Answer 34

D. A 270° posterior wrap Rationale: A Toupet fundoplication is a partial (270°) posterior wrap around the esophagus, often performed in patients with impaired esophageal motility to minimize post-surgical complications such as dysphagia.

Answer 35

C. Type III Rationale: A Type III hiatal hernia, also known as a mixed or combined hernia, is characterized by the upward dislocation of both the cardia and the gastric fundus into the thorax. It combines features of both a sliding hernia (type I) and a paraesophageal hernia (type II).

Answer 36

A. Adenocarcinoma Rationale: In the U.S., adenocarcinoma has become the most common form of esophageal cancer, largely due to the rising incidence of gastroesophageal reflux disease (GERD) and Barrett esophagus, which are risk factors for this type of cancer.

Answer 37

B. In the cervical and upper thoracic esophagus Rationale: Squamous cell carcinoma typically occurs in the cervical and upper thoracic parts of the esophagus. This form of esophageal cancer is associated with risk factors like smoking and alcohol consumption.

Answer 38

B. FEV1 (Forced Expiratory Volume in 1 second) Rationale: The FEV1 is the most important preoperative test for assessing a patient's ability to tolerate an esophagectomy. An FEV1 of 2 liters or more indicates sufficient cardiopulmonary reserve, while a value less than 1.25 liters is associated with a high risk of respiratory insufficiency postoperatively. Therefore, FEV1 is the best predictor of a patient's ability to undergo and recover from this procedure.

Answer 39

D. Endoscopic ultrasound (EUS) Rationale: Endoscopic ultrasound (EUS) is the most accurate method for determining the depth of cancer invasion in esophageal cancer. It provides detailed imaging of the esophageal layers and nearby lymph nodes, making it the most reliable tool for staging the disease and guiding surgical decision-making. Other imaging modalities like CT scans and MRIs are helpful but less precise for assessing the local invasion of the tumor.

Answer 40

D. Endoscopic ultrasound (EUS) Rationale: Endoscopic ultrasound (EUS) is the most accurate method for determining the depth of cancer invasion in esophageal cancer. It provides detailed imaging of the esophageal layers and nearby lymph nodes, making it the most reliable tool for staging the disease and guiding surgical decision-making. Other imaging modalities like CT scans and MRIs are helpful but less precise for assessing the local invasion of the tumor.

Answer 41

B. A 47-year-old woman with mid-esophageal cancer and involved cervical lymph nodes Rationale: Cervical lymph node involvement suggests more advanced disease that may not be amenable to esophagectomy. Patients with metastasis to cervical lymph nodes typically have a poor prognosis, and other treatment modalities such as chemoradiotherapy may be more appropriate.

Answer 42

B. Salvage esophagectomy Rationale: Salvage esophagectomy refers to the procedure performed when esophageal cancer remains symptomatic or progresses after definitive chemoradiotherapy. It is a challenging operation due to the scarring from previous radiation.

Answer 43

B. 2–3 months Rationale: Radiation therapy provides short-term relief from dysphagia in patients with esophageal cancer, with the benefit typically lasting 2–3 months. Radiation is often used for palliation in non-surgical candidates.

Answer 44

C. 6–8 weeks Rationale: Esophagectomy is optimally performed 6–8 weeks after completing neoadjuvant chemoradiotherapy to allow for recovery and minimize complications associated with inflammation or scar tissue formation.

Answer 45

C. Enucleation Rationale: Leiomyomas, though benign, are typically treated with enucleation, especially when they cause symptoms or are large. Observation may be considered for small, asymptomatic leiomyomas, but enucleation is recommended to prevent complications like dysphagia.

Answer 46

C. Left thoracotomy Rationale: Left thoracotomy provides the best exposure for esophageal ruptures near the gastroesophageal junction (GEJ). Early surgical intervention, usually within 24 hours, is critical for successful outcomes.

Answer 47

B. Observation Rationale: Most Mallory-Weiss tears heal spontaneously without the need for surgery or further intervention. Observation with supportive care, including blood replacement if necessary, is typically sufficient.

Answer 48

D. Either diverticulopexy or resection with cricopharyngeal myotomy Rationale: Treatment of a Zenker diverticulum involves either diverticulopexy (suturing in place) or resection, both combined with a cricopharyngeal myotomy to relieve the functional obstruction that caused the diverticulum.

Answer 49

B. Diffuse esophageal spasm (DES) Rationale: Diffuse esophageal spasm (DES) is characterized by simultaneous, non-peristaltic contractions of the esophagus, which can cause dysphagia and chest pain.

Answer 50

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.

Answer 51

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.

Answer 52

A. EGD Rationale: Esophagogastroduodenoscopy (EGD) is the gold standard for confirming GERD and assessing esophageal damage.

Answer 53

A. Start Proton Pump Inhibitor Rationale: Proton pump inhibitors are first-line management for GERD to reduce acid production and provide symptom relief.

Answer 54

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.

Answer 55

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.

Answer 56

A. Width of diaphragmatic hiatus Rationale: The function of the LES is not significantly influenced by the width of the diaphragmatic hiatus.

Answer 57

D. 6th cervical vertebra Rationale: The esophagus begins at the lower border of the 6th cervical vertebra, corresponding to the cricoid cartilage.

Answer 58

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.

Answer 59

E. 8th thoracic vertebra Rationale: The esophagus moves vertically to pass through the diaphragmatic hiatus at the level of the 8th thoracic vertebra.

Answer 60

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.

Answer 61

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.

Answer 62

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.

Answer 63

E. AOTA Rationale: Beta blockers, peptides bombesin, Substance P, and antacids all contribute to increasing the lower esophageal sphincter (LES) pressure.

Answer 64

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.

Answer 65

B. Paraesophageal hiatal hernia Rationale: The symptoms of postprandial pain, regurgitation, and relief with vomiting are suggestive of a paraesophageal hiatal hernia.

Answer 66

B. Barium Swallow Rationale: A barium swallow is the preferred diagnostic test for identifying the anatomical features of a paraesophageal hiatal hernia.

Answer 67

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.

Answer 68

B. Necrosis Rationale: If a paraesophageal hiatal hernia is not treated, the herniated portion of the stomach can become strangulated, leading to necrosis.

Answer 69

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.

Answer 70

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.

Answer 71

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.

Answer 72

E. Dysphagia Rationale: Dysphagia is a typical symptom of GERD, while the other options are atypical manifestations.

Answer 73

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.

Answer 74

D. A and B Rationale: Both acid and pepsin can cause severe epithelial injury when exposed to the esophageal mucosa.

Answer 75

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.

Answer 76

A. Dilatation alone

Answer 77

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.

Answer 78

B. Involved lymph nodes <2 Rationale: A smaller number of involved lymph nodes (<2) makes curative resection more likely in esophageal cancer.

Answer 79

D. Zenker’s diverticulum

Answer 80

B. Barium swallow Rationale: A barium swallow is often used to diagnose esophageal disorders, particularly structural abnormalities, by providing visualization of the esophagus.

Answer 81

D. Type IV Rationale: Type IV hiatal hernia involves herniation of other abdominal organs, such as the colon or spleen, into the thorax.

Answer 82

D. Lower Thoracic Esophagus Rationale: Esophageal adenocarcinoma is most commonly found in the distal esophagus, which is associated with gastroesophageal reflux disease (GERD).

Answer 83

B. Upper Thoracic Esophagus

Answer 84

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

Answer 85

A. Observation Rationale: For a patient with no symptoms or findings after caustic ingestion, observation is the best approach, with supportive care as necessary. EGD is usually performed if symptoms suggest injury.

Answer 86

C. Esophageal Cancer

Answer 87

A. EGD with biopsy

Answer 88

A. Observation

Answer 89

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. `

Answer 90

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.

Answer 91

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.

Answer 92

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.

Answer 93

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.

Answer 94

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.

Answer 95

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.

Answer 96

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.

Answer 97

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.

Answer 98

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.

Answer 99

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.

LE3 Esophagus Flashcards

(123 cards)