Oesophageal disorders

Questions

1.A 71-year-old patient was diagnosed with squamous cell carcinoma of the oesophagus.

Which of the following is a recognized risk factor for this disease?

A. Alcohol

B. Gastro-oesophageal reflux disease (GORD)

C.Helicobacter pylori (H. pylori) infection

D. Non-steroidal anti-inflammatory drugs

E. Obesity

2.A 63-year-old man presented to the gastroenterology clinic with progressive dysphagia to solid food. He was assessed as World Health Organization (WHO) performance status of 1.

Investigations:

Gastroscopy	A malignant-appearing oesophageal tumour is identified at 22 cm from the incisors.
Computed tomography (CT)	A 2 cm tumour is localized to the upper thoracic oesophagus. No distant metastases are seen on this scan.
neck, chest, and abdomen

Which investigation(s) would be most appropriate to stage this patient’s disease?

A. Positron emission tomography (PET)-CT

B. PET-CT and endoscopic ultrasound (EUS)

C. PET-CT, EUS, and staging laparoscopy

D. PET-CT, EUS, and tracheobronchoscopy

E. PET-CT, EUS, tracheobronchoscopy, and staging laparoscopy

3.A 70-year-old woman with a WHO performance status of 2 and mild inhaler controlled chronic obstructive pulmonary disease (COPD) was found on gastroscopy to have a 45 mm flat adenocarcinoma of the oesophagus at 35 cm, not bordering the gastro-oesophageal junction.

Investigations:

Endoscopic ultrasound	Tumour invades lamina propria but not submucosa, no regional lymphadenopathy
PET-CT chest, abdomen, pelvis	No evidence of lymphadenopathy, no distant metastases

Which is the next best option in her management?

A.Chemoradiotherapy

B.Endoscopic mucosal resection (EMR)

C. Palliative care

D.Radiofrequency ablation

E.Surgical resection

4.A 76-year-old man was diagnosed with metastatic oesophageal adenocarcinoma. A self-expanding metal stent (SEMS) was inserted to relieve his dysphagia but he requested this to be removed because of persistent chest discomfort in the absence of oesophageal perforation. His WHO performance status was 3.

Which of the following is a useful option in the palliation of dysphagia for this patient?

A. Botulinum toxin injection

B. Brachytherapy

C. Calcium channel blockers

D. Chemotherapy

E. Local ethanol injection

5.An 83-year-old man with T4N1M1 oesophageal adenocarcinoma was admitted with progressive dysphagia. He requested to be managed symptomatically and a SEMS had been suggested.

Which of the following statements is true regarding SEMS in malignant oesophageal strictures?

A. Brachytherapy should not be used at the same time as SEMS placement

B. Photodynamic therapy is superior to SEMS in the palliation of malignant dysphagia

C. SEMS is contraindicated in the presence of a tracheo-oesophageal fistula

D. SEMS should be inserted in advance of palliative radiotherapy for dysphagia

E. SEMS should not be used as a bridge to definitive surgery

6.A 47-year-old man attended for a gastroscopy to investigate persistent hoarseness of voice, cough, and sore throat. He had previously seen the ear, nose, and throat team who had performed flexible nasendoscopy and commented that the laryngeal folds were mildly erythematous. They wondered whether his symptoms were caused by acid reflux.

Investigations:

Gastroscopy

A salmon-coloured area was seen at 18 cm from the incisors (Fig. 2.1). Otherwise this was a normal endoscopy.

Fig. 2.1 Endoscopic image of upper oesophagus. See also Plate 2

Image courtesy of Oxford University Hospitals NHS Foundation Trust

What is the diagnosis?

A. Barrett’s oesophagus

B. Candidiasis

C. Cervical inlet patch

D. Squamous cell carcinoma

E. Tracheo-oesophageal fistula

7.A 46-year-old man was reviewed in clinic with a two-year history of heartburn and regurgitation. His symptoms persisted despite omeprazole 40 mg twice daily.

Investigations:

Gastroscopy	No evidence of erosive oesophagitis
Oesophageal histology	Four eosinophils per high-power field

What is the next most appropriate step?

A. Barium swallow

B. Fasting gastrin level

C. Long-term metoclopramide

D. Oesophageal pH/impedence studies

E. Trial of swallowed budesonide

8.A 53-year-old man was reviewed for persistent heartburn and nocturnal cough despite omeprazole 40 mg twice daily and lifestyle optimization. A gastroscopy two years previously had demonstrated LA Grade C oesophagitis, and recent pH/impedence monitoring confirmed ongoing pathological acid reflux. Manometry was normal. He was keen to explore surgical options to manage his condition.

Which of the following statements about anti-reflux surgery is most accurate?

A. Laparoscopic fundoplication is less effective than open fundoplication at relieving heartburn and regurgitation but has lower mortality

B. Laparoscopic magnetic sphincter augmentation results in lower rates of gas bloating than laparoscopic Nissen fundoplication

C. Most patients with post-operative dysphagia will require revisional surgery

D. Nissen fundoplication is preferred over Toupet fundoplication for patients with oesophageal motility disorders

E. Transoral incisionless fundoplication is the operation of choice for most patients

9.A 71-year-old woman was reviewed in clinic following a surveillance endoscopy for Barrett’s oesophagus.

Which of the following histopathological features best supports a diagnosis of Barrett’s oesophagus without dysplasia?

A.Cardiac-type columnar cells bordering squamous mucosa

B.columnar mucosa with nuclear pleomorphism in all cells seen

C.gastric-type mucosa with a similarity in nuclear/cytological appearances between the crypt base cells and those at the surface epithelium

D.increased foci of mitotic activity seen at the gastro-oesophageal junction

E.intestinal metaplastic glandular mucosa with adjacent oesophageal ducts

10.A 63-year-old man attended for surveillance gastroscopy for Barrett’s oesophagus.

Investigations:

Gastroscopy	C3M6 Barrett’s oesophagus with no visible lesions
Histology	Consistent with Barrett’s oesophagus with evidence of low-grade dysplasia in two biopsies (confirmed by a second expert gastrointestinal pathologist)

How should he be managed?

A. Endoscopic resection of Barrett’s oesophagus

B. Laparoscopic oesophagectomy

C. Radiofrequency ablation

D. Repeat endoscopy in six months

E. Repeat endoscopy in 12 months

11.A 53-year-old man attended for a gastroscopy to investigate persistent reflux symptoms.

Investigations:

Gastroscopy	C5M7 Barrett’s oesophagus
Histology	Consistent with Barrett’s oesophagus with intestinal metaplasia (IM) but no evidence of dysplasia

The patient is keen for surveillance because he is concerned about the risk of oesophageal cancer. When should he receive his next endoscopy?

A. Between two and three years

B. Between three and five years

C. Between eight and ten years

D. No surveillance

E. Within six months to confirm the diagnosis

12.A 67-year-old woman with Barrett’s oesophagus was found to have an area of high grade dysplasia at recent surveillance endoscopy.

Regarding visible foci of high-grade dysplasia in Barrett’s oesophagus, which of the following statements are true?

A. Fewer than 5% of patients with a visible dysplastic focus will develop metachronous lesions over the subsequent two years

B. Once the focus of high-grade dysplasia has been resected, the patient should receive surveillance endoscopy after two years

C. PET-CT should be performed prior to endoscopic resection of high-grade dysplasia

D. The ‘cap and snare’ technique is more effective at resecting visible lesions than band ligation

E. When endoscopic resection is performed, histological examination of the resection specimen is the most accurate staging technique for Barrett’s oesophagus-related early neoplasia

13.A 75-year-old man presented with a six-month history of non-cardiac chest pain and intermittent dysphagia to solids and liquids.

Investigations:

Gastroscopy	Grade A reflux oesophagitis
Oesophageal manometry	Average distal peristaltic amplitude >180 mmHg

What is the diagnosis?

A. Achalasia

B. Diffuse oesophageal spasm

C. Hypertensive lower oesophageal sphincter

D. Ineffective oesophageal motility

E. Nutcracker oesophagus

14.A 37-year-old Brazilian man with a history of non-cardiac chest pain was referred to the gastroenterology clinic by cardiology. He described a history of episodic dysphagia and occasional regurgitation that persisted despite PPI therapy and a short trial of prokinetics.

Investigations:

Gastroscopy	Normal
Oesophageal pH studies	DeMeester score 11.3
Oesophageal motility studies	Premature contractions in 35% of swallows; normal relaxation of the gastro-oesophageal junction during swallowing. The distal contractile integral never exceeds 8,000 mmHg/cm/s.

What is the most likely diagnosis?

A.Achalasia

B. Chagas disease

C.Distal (diffuse) oesophageal spasm

D.GORD

E.Jackhammer oesophagus

15.A 44-year-old patient presented with a two-year history of progressive dysphagia and occasional retrosternal discomfort. Dysphagia occurred for both solids and liquids. Following a normal upper gastrointestinal endoscopy, the patient underwent high-resolution oesophageal manometry.

Investigations:

High resolution oesophageal manometry (Fig. 2.2)

Integrated relaxation pressure (IRP) 28 mmHg (normal <15)

Distal contractile integral (DCI) 90 (normal 450–8,000)

Distal latency (DL)—not calculated as DCI <450

Fig. 2.2 Pressure topography plot obtained during high resolution oesophageal manometry. See also Plate 3

Image courtesy of Dr Tanya Miller, Principal Clinical Scientist in GI Physiology, Oxford University Hospitals NHS Foundation Trust

What is the most likely diagnosis?

A. Absent contractility

B. Pseudoachalasia

C. Type I achalasia

D. Type II achalasia

E. Type III achalasia

16.A 64-year-old Argentinian man presented to the gastroenterology clinic complaining of dysphagia and regurgitation of undigested food. Systemic examination revealed an irregular pulse and pitting oedema of the lower limbs.

Investigations:

Gastroscopy

Grossly dilated oesophagus containing undigested food and fluid. The lower oesophageal sphincter was slow to relax with otherwise normal appearances to the oesophago-gastric junction.

Which of the following investigations would confirm the diagnosis?

A. CT thorax

B. High-resolution oesophageal manometry

C. Thick and thin film microscopy with Giemsa stain

D.Treponema whipplei serology

E.Trypanosoma cruzi serology

17.An 87-year-old man presented with weight loss, one year of worsening dysphagia and regurgitation of both solids and liquids. Past medical history included ischaemic heart disease, hypertension, chronic kidney disease, and recurrent falls.

Investigations:

Gastroscopy	Dilated oesophagus with some food residue, normal stomach and duodenum
CT chest, abdomen and pelvis	No extrinisic compression of the gastro-oesophageal junction (Fig. 2.3)

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