Esophageal achalasia is characterized by
A. Absence of esophageal peristalsis
B. Heartburn in more than 50% of patients
C. Low intraluminal pH due to GERD
A. Absence of esophageal peristalsis. Esophageal manometry is the gold standard for establishing the diagnosis of esophageal achalasia. The classic manometric findings are: (1) absence of esophageal peristalsis and (2) hypertensive LES (in about 50% of patients) that relaxes only partially in response to swallowing. Dysphagia for both solid and liquid food is the most common symptom, experienced by virtually every patient. Heartburn is present in about 40% of patients. As the low intraluminal pH, it is not due to GER, but rather to stasis and fermentation of undigested food in the distal esophagus.
Which of the following sentences about Zenker diverticulum is wrong?
A. It is the most common diverticulum of the esophagus.
B. It is a consequence of an underlying esophageal motility disorder.
C. Aspiration of diverticular contents is frequent.
D. The surgical treatment consists of LES myotomy, resection of the diverticulum or its suspension.
D. The surgical treatment consists of LES myotomy, resection of the diverticulum or its suspension. Although rare, Zenker diverticulum is more common than the epiphrenic diverticulum. It is a protrusion of pharyngeal mucosa through a weak zone in the Killian’s triangle, secondary to abnormalities of the UES sphincter. Dysphagia occurs very frequently. As the pouch enlarges, its contents can be inhaled into the respiratory tree causing chronic cough and pneumonia. Finally, the established treatment consists of eliminating the functional obstruction performing a UES myotomy, associated with resection or suspension of the diverticulum.
A 54-year-old patient has heartburn. The correct workup includes
A. Esophageal manometry, 24-hour pH monitoring and upper endoscopy.
B. Upper endoscopy and 24-hour pH monitoring.
C. Nothing, the patient has gastro-esophageal reflux and needs surgery.
D. Nothing; the patient has gastro-esophageal reflux and needs treatment with proton pump inhibitors.
A. Esophageal manometry, 24-hour pH monitoring and upper endoscopy. Heartburn, along with regurgitation and dysphagia is considered a typical symptom of gastroesophageal reflux (GERD). However, a clinical diagnosis of GERD based on these symptoms is correct in only 70% of patients (when compared with the results of pH monitoring). Heartburn can also be caused by nonesophageal disorders such as biliary disease, irritable bowel syndrome, coronary artery disease, and psychiatric diseases. Esophageal manometry is mandatory to evaluate the function of both the esophageal body and LES. In addition, manometry is essential for proper placement of the pH probe for ambulatory pH monitoring. Twenty-four-hour pH monitoring measures reflux of acid from the stomach into the esophagus and correlate it to the symptoms. Upper endoscopy visualizes the mucosal surface of the esophagus, determines the presence and degree of esophagitis and allows biopsies.
A. Becomes more symptomatic over time due to the mucosal inflammation
B. Is linked to duodeno-gastro-esophageal reflux
C. Is classified short if less than 2 cm
D. Is characterized by the presence of fundic type cells
B. Is linked to duodeno-gastro-esophageal reflux. Barrett esophagus is defined as a change in the esophageal mucosa with replacement of the squamous epithelium by columnar epithelium. It is classified into short segment if less than 3 cm in length or long segment if 3 cm or longer. Barrett esophagus represents an adaptation of the esophageal mucosa to the acid and duodenal juice from the stomach. The diagnosis is confirmed by pathologic examination of the esophageal mucosa and requires the identification of goblet cells, typical for intestinal epithelium. Patients with BE have typically a long history of GERD. Nevertheless, they may become asymptomatic over time due to the decreased sensitivity of the metaplastic epithelium.
Treatment of esophageal cancer includes
A. EMR/RFA for a T1a lesion
B. Neoadjuvant therapy followed by surgery for locally advanced cancer
C. Intraesophageal stenting for patients with dysphagia and solid organ metastases
D. All of the above. In patients with early esophageal cancer (pT1a), an esophagectomy can be avoided, because of the very low risk of lymph nodes metastasis (0%-3%), and EMR and RFA are very effective. Unlike intramucosal cancer (T1a), T1b cancer has a high risk of lymph node metastases (20%-30% vs. 0%-3%), and therefore esophageal resection is the treatment of choice. In case of locally advanced esophageal cancer (T3-4N0-3, T2N1-3), chemo-radiation is the best treatment, followed by surgery. It seems that the combination of neoadjuvant therapy followed by surgery offers the best survival benefit. This is particularly true in the subgroup of patients (about 20%) who have a “complete pathologic response” (no tumor found in the specimen). In patients with distant metastases, survival is very poor and treatment modalities focus on the palliation of symptoms. Endoscopic stenting is one of the most successful options in the treatment of dysphagia.