Master the Boards USMLE Step 2CK - Gastroenterology
Essential feature of the majority of esophageal disorders
Dysphagia
Difficulty swallowing
Dysphagia
Proper term for pain while swallowing
Odynophagia
Both dysphagia & odynophagia can lead to?
Weight loss
When severe, some forms of esophageal disorder will also give rise to what?
- Anemia
- Heme+ stool
What should be done when gastrointestinal alarm symptoms are present?
Endoscopy
Alarm symptoms indicating endoscopy
- Weight loss
- Blood in stool
- Anemia
Inability of the lower esophageal sphincter (LES) to relax (aperistalsis of the esophageal
body) due to a loss of the nerve plexus within the lower esophagus
Achalasia
Etiology of achalasia
Not clear
Presentation of achalasia
- Young patient < 50 y/o
- Progressive dysphagia to both solids & liquids at the same time
- No association w/ alcohol & tobacco use
Findings on barium esophagram associated w/ achalasia
"Bird's beak" as the esophagus comes down to a point
Most accurate diagnostic test used to diagnose achalasia
Manometry
Findings on manometry associated w/ achalasia
Failure of the lower esophageal sphincter to relax
CXR findings associated w/ achalasia
Abnormal widening of the esophagus
How useful is a CXR in the diagnosis of achalasia?
Not very useful as it is neither very sensitive nor very specific
Mucosal findings associated w/ achalasia on upper endoscopy
Normal mucosa
,When is endoscopy useful in the setting of achalasia?
To exclude malignancy in some patients
With regards to the esophagus, what studies are acceptable to do first in most patients?
Barium studies
With regards to the esophagus,, what studies ALWAYS lack the specificity of
endoscopic procedures?
Radiologic tests
Can the normal function of the missing neurological control of the esophagus
associated w/ achalasia be restored/"cured"?
No, all treatment is based on mechanical dilation of the esophagus
Treatment of achalasia
1. Pneumatic dilation
2. Surgical sectioning or myotomy
3. Botulinum toxin injection
Procedure where an endscope w/ the ability to inflate a device that will enlarge the
esophagus is placed
Pneumatic dilation
Effectiveness of pneumatic dilation in the treatment of achalasia
80-85%
In what % of patients does pneumatic dilation lead to perforation in the treatment of
achalasia?
< 3%
Treatment option that is more effective but more dangerous than pneumatic dilation in
the treatment of achalasia
Surgical sectioning or myotomy
Treatment option that will relax the lower esophageal sphincter but will wear off in about
3-6 months, requiring retreatment
Botulinum toxin injection
With regards to the esophagus,, what are the only 2 pathologies diagnosed by biopsy?
- Cancer
- Barrett esopagus
Presentation of esophageal cancer
- ≥ 50 y/o
- Dysphagia first for solids, progressing to dysphagia for liquids
- Associated w/ prolonged alcohol & tobacco use
- > 5-10 years of GERD symptoms
Most important clue to the diagnosis of esophageal cancer
The single word "progressive" or "from solids to liquids"
Indispensible test in making the diagnosis of esophageal cancer
Endoscopy
Why is endoscopy an indispensable test in making the diagnosis of esophageal cancer?
Only a biopsy can diagnose cancer
_____ might be the "best initial test", but no radiologic test can diagnose cancer
Barium
What types of imaging are not enough to diagnose esophageal cancer?
CT & MRI
,For cancer, what is never the most accurate?
Radiologic tests
Utility of CT & MRI in the setting of esophageal cancer
Determine the extent of spread into the surrounding tissues
In the setting of esophageal cancer, what is used to determine the contents of anatomic
lesions if you are not certain whether they contain cancer?
PET scan
In addition to determining the contents of anatomic lesions what is another use for the
PET scan?
Determine whether a cancer is resectable
Generally, what type of cancer (local vs. widely metastatic) is resectable?
- Local disease is resectable
- Widely metastatic disease is not
Treatment of esophageal cancer
1. Surgical resection
2. Chemotherapy + radiation following surgical removal
3. Stent placement for lesions that cannot be resected surgically
Rationale for stent placement in the treatment for esophageal cancer
- To keep the esophagus open for palliation
- To improve dysphagia
2 clinically indistinguishable forms of spastic disorders affecting the esopagus
- Diffuse esophageal spasm (DES)
- Nutcracker esophagus
Presentation of spastic disorders affecting the esophagus
Sudden onset of chest pain that is not related to exertion
Conditions that are impossible to distinguish spastic disorders affecting the esophagus
from at first
- Atypical coronary artery spasm
- Unstable angina
How are the spastic disorders affecting the esophagus precipitated?
By drinking cold liquid
Common symptoms and exam findings associated with spastic disorders affecting the
esophagus
- Sudden severe chest pain
- Normal EKG
- Normal stress test
Findings on esophagram and endoscopy associated with spastic disorders affecting the
esophagus
Normal
Most accurate test used to distinguish between diffuse esophageal spasm and
nutcracker esophagus
Manometry
Findings on manometry associated with the spastic disorders affecting the esophagus
Different patterns of abnormal contraction
Findings on barium studies associated with esophageal spasm
Corkscrew appearance at the time of the spasm
, Treatment of esophageal spastic disorders
- Calcium channel blockers
- Nitrates
What does the treatment of esophageal spastic disorders resemble?
Treatment of Prinzmetal angina
What other drug improves a number of cases of spastic disease of the esophagus?
PPIs
A 43-year-old man recently diagnosed with AIDS comes to the emergency department
with pain on swallowing that has become progressively worse over the last several
weeks. There is no pain when not swallowing. His CD4 count is 43 ㎣. The patient is not
currently taking any medications. What is the most appropriate next step in
management?
A. Esophogram
B. Upper endoscopy
C. Oral nystatin swish and swallow
D. Intravenous amphotericin
E. Oral fluconazole
E. Oral fluconazole
Most commonly asked infectious esophagitis question
Esophageal candidiasis in a person with AIDS
Does oral candidiasis/thrush need to be present in esophageal candidiasis?
No, one does not automatically follow from the other
Most common infectious agent implicated in esophageal infection
Candida
Other infectious agents implicated in esophageal infection
- CMV
- Herpes
Best course of action in the setting of esophageal candidiasis
Empiric therapy with fluconazole
What is the next step if empiric therapy with fluconazole does not improve the
symptoms of esophageal candidiasis?
Endoscopy
What medication is used to treat confirmed esophageal candidiasis not responding to
fluconazole?
Intravenous amphotericin
Is oral nystatin swish and swallow sufficient to control esophageal candidiasis?
No
Treatment of oral candidiasis
Oral nystatin swish and swallow
Medications associated with esophagitis with prolonged contact
Essential feature of the majority of esophageal disorders
Dysphagia
Difficulty swallowing
Dysphagia
Proper term for pain while swallowing
Odynophagia
Both dysphagia & odynophagia can lead to?
Weight loss
When severe, some forms of esophageal disorder will also give rise to what?
- Anemia
- Heme+ stool
What should be done when gastrointestinal alarm symptoms are present?
Endoscopy
Alarm symptoms indicating endoscopy
- Weight loss
- Blood in stool
- Anemia
Inability of the lower esophageal sphincter (LES) to relax (aperistalsis of the esophageal
body) due to a loss of the nerve plexus within the lower esophagus
Achalasia
Etiology of achalasia
Not clear
Presentation of achalasia
- Young patient < 50 y/o
- Progressive dysphagia to both solids & liquids at the same time
- No association w/ alcohol & tobacco use
Findings on barium esophagram associated w/ achalasia
"Bird's beak" as the esophagus comes down to a point
Most accurate diagnostic test used to diagnose achalasia
Manometry
Findings on manometry associated w/ achalasia
Failure of the lower esophageal sphincter to relax
CXR findings associated w/ achalasia
Abnormal widening of the esophagus
How useful is a CXR in the diagnosis of achalasia?
Not very useful as it is neither very sensitive nor very specific
Mucosal findings associated w/ achalasia on upper endoscopy
Normal mucosa
,When is endoscopy useful in the setting of achalasia?
To exclude malignancy in some patients
With regards to the esophagus, what studies are acceptable to do first in most patients?
Barium studies
With regards to the esophagus,, what studies ALWAYS lack the specificity of
endoscopic procedures?
Radiologic tests
Can the normal function of the missing neurological control of the esophagus
associated w/ achalasia be restored/"cured"?
No, all treatment is based on mechanical dilation of the esophagus
Treatment of achalasia
1. Pneumatic dilation
2. Surgical sectioning or myotomy
3. Botulinum toxin injection
Procedure where an endscope w/ the ability to inflate a device that will enlarge the
esophagus is placed
Pneumatic dilation
Effectiveness of pneumatic dilation in the treatment of achalasia
80-85%
In what % of patients does pneumatic dilation lead to perforation in the treatment of
achalasia?
< 3%
Treatment option that is more effective but more dangerous than pneumatic dilation in
the treatment of achalasia
Surgical sectioning or myotomy
Treatment option that will relax the lower esophageal sphincter but will wear off in about
3-6 months, requiring retreatment
Botulinum toxin injection
With regards to the esophagus,, what are the only 2 pathologies diagnosed by biopsy?
- Cancer
- Barrett esopagus
Presentation of esophageal cancer
- ≥ 50 y/o
- Dysphagia first for solids, progressing to dysphagia for liquids
- Associated w/ prolonged alcohol & tobacco use
- > 5-10 years of GERD symptoms
Most important clue to the diagnosis of esophageal cancer
The single word "progressive" or "from solids to liquids"
Indispensible test in making the diagnosis of esophageal cancer
Endoscopy
Why is endoscopy an indispensable test in making the diagnosis of esophageal cancer?
Only a biopsy can diagnose cancer
_____ might be the "best initial test", but no radiologic test can diagnose cancer
Barium
What types of imaging are not enough to diagnose esophageal cancer?
CT & MRI
,For cancer, what is never the most accurate?
Radiologic tests
Utility of CT & MRI in the setting of esophageal cancer
Determine the extent of spread into the surrounding tissues
In the setting of esophageal cancer, what is used to determine the contents of anatomic
lesions if you are not certain whether they contain cancer?
PET scan
In addition to determining the contents of anatomic lesions what is another use for the
PET scan?
Determine whether a cancer is resectable
Generally, what type of cancer (local vs. widely metastatic) is resectable?
- Local disease is resectable
- Widely metastatic disease is not
Treatment of esophageal cancer
1. Surgical resection
2. Chemotherapy + radiation following surgical removal
3. Stent placement for lesions that cannot be resected surgically
Rationale for stent placement in the treatment for esophageal cancer
- To keep the esophagus open for palliation
- To improve dysphagia
2 clinically indistinguishable forms of spastic disorders affecting the esopagus
- Diffuse esophageal spasm (DES)
- Nutcracker esophagus
Presentation of spastic disorders affecting the esophagus
Sudden onset of chest pain that is not related to exertion
Conditions that are impossible to distinguish spastic disorders affecting the esophagus
from at first
- Atypical coronary artery spasm
- Unstable angina
How are the spastic disorders affecting the esophagus precipitated?
By drinking cold liquid
Common symptoms and exam findings associated with spastic disorders affecting the
esophagus
- Sudden severe chest pain
- Normal EKG
- Normal stress test
Findings on esophagram and endoscopy associated with spastic disorders affecting the
esophagus
Normal
Most accurate test used to distinguish between diffuse esophageal spasm and
nutcracker esophagus
Manometry
Findings on manometry associated with the spastic disorders affecting the esophagus
Different patterns of abnormal contraction
Findings on barium studies associated with esophageal spasm
Corkscrew appearance at the time of the spasm
, Treatment of esophageal spastic disorders
- Calcium channel blockers
- Nitrates
What does the treatment of esophageal spastic disorders resemble?
Treatment of Prinzmetal angina
What other drug improves a number of cases of spastic disease of the esophagus?
PPIs
A 43-year-old man recently diagnosed with AIDS comes to the emergency department
with pain on swallowing that has become progressively worse over the last several
weeks. There is no pain when not swallowing. His CD4 count is 43 ㎣. The patient is not
currently taking any medications. What is the most appropriate next step in
management?
A. Esophogram
B. Upper endoscopy
C. Oral nystatin swish and swallow
D. Intravenous amphotericin
E. Oral fluconazole
E. Oral fluconazole
Most commonly asked infectious esophagitis question
Esophageal candidiasis in a person with AIDS
Does oral candidiasis/thrush need to be present in esophageal candidiasis?
No, one does not automatically follow from the other
Most common infectious agent implicated in esophageal infection
Candida
Other infectious agents implicated in esophageal infection
- CMV
- Herpes
Best course of action in the setting of esophageal candidiasis
Empiric therapy with fluconazole
What is the next step if empiric therapy with fluconazole does not improve the
symptoms of esophageal candidiasis?
Endoscopy
What medication is used to treat confirmed esophageal candidiasis not responding to
fluconazole?
Intravenous amphotericin
Is oral nystatin swish and swallow sufficient to control esophageal candidiasis?
No
Treatment of oral candidiasis
Oral nystatin swish and swallow
Medications associated with esophagitis with prolonged contact
