NR 603 – CEA GI Practice Questions
with Answers & Rationales
SECTION 1: ESOPHAGEAL DISORDERS (Questions 1–15)
1. A 45-year-old male presents with a 5-year history of heartburn. He reports
a sensation of a lump in his throat (globus sensation) and a chronic cough.
What is the most appropriate initial diagnostic test?
A) Empiric PPI trial for 8 weeks
B) Esophagogastroduodenoscopy (EGD) with biopsy
C) Upper GI barium swallow
D) Esophageal manometry
Answer: B) Esophagogastroduodenoscopy (EGD) with biopsy
Rationale: While an empiric PPI trial is common in patients without alarm
symptoms, this patient's chronic symptoms and globus sensation warrant EGD with
biopsy to rule out Barrett's esophagus, a premalignant condition associated with
chronic GERD. EGD allows direct visualization and tissue sampling to assess for
dysplasia.
2. A patient with GERD fails high-dose PPI therapy. Manometry reveals
hypotensive lower esophageal sphincter (LES) pressure and ineffective
esophageal motility. What is the next step in management?
A) Increase PPI to maximum dose
B) Add a prokinetic agent
C) Consider fundoplication or magnetic sphincter augmentation (LINX)
D) Prescribe H2 receptor antagonists
Answer: C) Consider fundoplication or magnetic sphincter augmentation
(LINX)
,Rationale: Patients who fail maximal medical therapy and have documented LES
dysfunction are candidates for surgical intervention. Fundoplication or LINX
device placement can restore the antireflux barrier. This decision should be made
after confirming no contraindications.
3. A 60-year-old presents with progressive dysphagia to both solids and
liquids, regurgitation of undigested food, and chest pain. Barium swallow
shows a "bird-beak" appearance at the gastroesophageal junction. What is
the diagnosis and first-line non-surgical treatment?
A) Diffuse esophageal spasm; calcium channel blockers
B) Achalasia; pneumatic dilation
C) Esophageal stricture; dilation with Savary dilators
D) Eosinophilic esophagitis; topical steroids
Answer: B) Achalasia; pneumatic dilation
Rationale: The classic "bird-beak" appearance on barium swallow is
pathognomonic for achalasia, a disorder of esophageal motility characterized by
failure of LES relaxation. First-line non-surgical treatment is pneumatic dilation.
Laparoscopic Heller myotomy is the surgical option. Botulinum toxin is reserved
for poor surgical candidates.
4. A patient reports sudden, severe retrosternal chest pain after a large meal,
followed by dysphagia and odynophagia. CT chest shows intramural air
tracking in the esophageal wall. What is the diagnosis?
A) Mallory-Weiss tear
B) Boerhaave syndrome
C) Esophageal diverticulum
D) Peptic stricture
Answer: B) Boerhaave syndrome
Rationale: Boerhaave syndrome is a spontaneous esophageal rupture (full-
thickness perforation) often caused by sudden increases in intraesophageal
,pressure, such as after vomiting or a large meal. CT showing intramural air is a key
finding. This is a surgical emergency. Mallory-Weiss tears are mucosal lacerations
managed conservatively.
5. What is the gold standard for diagnosing eosinophilic esophagitis (EoE)?
A) Clinical symptom improvement with PPI
B) Peripheral eosinophil count
C) Esophageal biopsy showing ≥15 eosinophils per high-power field after PPI trial
D) Barium swallow showing trachealization
Answer: C) Esophageal biopsy showing ≥15 eosinophils per high-power field
after PPI trial
Rationale: EoE is diagnosed by esophageal biopsy demonstrating ≥15 eosinophils
per high-power field. A PPI trial is essential to rule out PPI-responsive esophageal
eosinophilia, which can mimic EoE clinically and histologically.
6. A patient with EoE presents with food impaction. What is the immediate
management?
A) Administer glucagon to relax the esophagus
B) Endoscopic removal of the impacted food bolus
C) Prescribe oral steroids to reduce inflammation
D) Have the patient drink carbonated beverage to dislodge food
Answer: B) Endoscopic removal of the impacted food bolus
Rationale: Food impaction in EoE requires endoscopic removal, ideally with
careful extraction using a net or snare. Excessive force should be avoided to
prevent esophageal perforation. Glucagon is rarely effective and not recommended
as first-line therapy.
, 7. A 55-year-old with long-standing GERD undergoes surveillance EGD.
Biopsies reveal intestinal metaplasia in the distal esophagus. What is the most
appropriate next step?
A) Reassure the patient and repeat EGD in 5 years
B) Start high-dose PPI and repeat EGD in 1 year
C) Refer for esophagectomy
D) Begin surveillance every 3–5 years based on dysplasia grade
Answer: D) Begin surveillance every 3–5 years based on dysplasia grade
Rationale: Intestinal metaplasia in the distal esophagus is diagnostic of Barrett's
esophagus, a premalignant condition. Surveillance intervals depend on the
presence and grade of dysplasia: no dysplasia = 3–5 years, low-grade dysplasia =
6–12 months, high-grade dysplasia = more frequent surveillance or intervention.
8. A 38-year-old woman presents with intermittent dysphagia to solids, chest
pain, and heartburn that does not respond to PPIs. EGD is normal.
Esophageal manometry shows simultaneous contractions with high amplitude.
What is the most likely diagnosis?
A) Achalasia
B) Diffuse esophageal spasm
C) GERD
D) Scleroderma esophagus
Answer: B) Diffuse esophageal spasm
Rationale: Diffuse esophageal spasm is characterized by intermittent dysphagia
and chest pain with manometry showing simultaneous (non-peristaltic)
contractions of high amplitude. EGD is typically normal. This distinguishes it from
achalasia (absent peristalsis with impaired LES relaxation).
9. A patient with GERD develops dysphagia and odynophagia. EGD reveals a
white, plaque-like exudate in the distal esophagus. Biopsy shows fungal
hyphae and yeast. What is the most appropriate treatment?
with Answers & Rationales
SECTION 1: ESOPHAGEAL DISORDERS (Questions 1–15)
1. A 45-year-old male presents with a 5-year history of heartburn. He reports
a sensation of a lump in his throat (globus sensation) and a chronic cough.
What is the most appropriate initial diagnostic test?
A) Empiric PPI trial for 8 weeks
B) Esophagogastroduodenoscopy (EGD) with biopsy
C) Upper GI barium swallow
D) Esophageal manometry
Answer: B) Esophagogastroduodenoscopy (EGD) with biopsy
Rationale: While an empiric PPI trial is common in patients without alarm
symptoms, this patient's chronic symptoms and globus sensation warrant EGD with
biopsy to rule out Barrett's esophagus, a premalignant condition associated with
chronic GERD. EGD allows direct visualization and tissue sampling to assess for
dysplasia.
2. A patient with GERD fails high-dose PPI therapy. Manometry reveals
hypotensive lower esophageal sphincter (LES) pressure and ineffective
esophageal motility. What is the next step in management?
A) Increase PPI to maximum dose
B) Add a prokinetic agent
C) Consider fundoplication or magnetic sphincter augmentation (LINX)
D) Prescribe H2 receptor antagonists
Answer: C) Consider fundoplication or magnetic sphincter augmentation
(LINX)
,Rationale: Patients who fail maximal medical therapy and have documented LES
dysfunction are candidates for surgical intervention. Fundoplication or LINX
device placement can restore the antireflux barrier. This decision should be made
after confirming no contraindications.
3. A 60-year-old presents with progressive dysphagia to both solids and
liquids, regurgitation of undigested food, and chest pain. Barium swallow
shows a "bird-beak" appearance at the gastroesophageal junction. What is
the diagnosis and first-line non-surgical treatment?
A) Diffuse esophageal spasm; calcium channel blockers
B) Achalasia; pneumatic dilation
C) Esophageal stricture; dilation with Savary dilators
D) Eosinophilic esophagitis; topical steroids
Answer: B) Achalasia; pneumatic dilation
Rationale: The classic "bird-beak" appearance on barium swallow is
pathognomonic for achalasia, a disorder of esophageal motility characterized by
failure of LES relaxation. First-line non-surgical treatment is pneumatic dilation.
Laparoscopic Heller myotomy is the surgical option. Botulinum toxin is reserved
for poor surgical candidates.
4. A patient reports sudden, severe retrosternal chest pain after a large meal,
followed by dysphagia and odynophagia. CT chest shows intramural air
tracking in the esophageal wall. What is the diagnosis?
A) Mallory-Weiss tear
B) Boerhaave syndrome
C) Esophageal diverticulum
D) Peptic stricture
Answer: B) Boerhaave syndrome
Rationale: Boerhaave syndrome is a spontaneous esophageal rupture (full-
thickness perforation) often caused by sudden increases in intraesophageal
,pressure, such as after vomiting or a large meal. CT showing intramural air is a key
finding. This is a surgical emergency. Mallory-Weiss tears are mucosal lacerations
managed conservatively.
5. What is the gold standard for diagnosing eosinophilic esophagitis (EoE)?
A) Clinical symptom improvement with PPI
B) Peripheral eosinophil count
C) Esophageal biopsy showing ≥15 eosinophils per high-power field after PPI trial
D) Barium swallow showing trachealization
Answer: C) Esophageal biopsy showing ≥15 eosinophils per high-power field
after PPI trial
Rationale: EoE is diagnosed by esophageal biopsy demonstrating ≥15 eosinophils
per high-power field. A PPI trial is essential to rule out PPI-responsive esophageal
eosinophilia, which can mimic EoE clinically and histologically.
6. A patient with EoE presents with food impaction. What is the immediate
management?
A) Administer glucagon to relax the esophagus
B) Endoscopic removal of the impacted food bolus
C) Prescribe oral steroids to reduce inflammation
D) Have the patient drink carbonated beverage to dislodge food
Answer: B) Endoscopic removal of the impacted food bolus
Rationale: Food impaction in EoE requires endoscopic removal, ideally with
careful extraction using a net or snare. Excessive force should be avoided to
prevent esophageal perforation. Glucagon is rarely effective and not recommended
as first-line therapy.
, 7. A 55-year-old with long-standing GERD undergoes surveillance EGD.
Biopsies reveal intestinal metaplasia in the distal esophagus. What is the most
appropriate next step?
A) Reassure the patient and repeat EGD in 5 years
B) Start high-dose PPI and repeat EGD in 1 year
C) Refer for esophagectomy
D) Begin surveillance every 3–5 years based on dysplasia grade
Answer: D) Begin surveillance every 3–5 years based on dysplasia grade
Rationale: Intestinal metaplasia in the distal esophagus is diagnostic of Barrett's
esophagus, a premalignant condition. Surveillance intervals depend on the
presence and grade of dysplasia: no dysplasia = 3–5 years, low-grade dysplasia =
6–12 months, high-grade dysplasia = more frequent surveillance or intervention.
8. A 38-year-old woman presents with intermittent dysphagia to solids, chest
pain, and heartburn that does not respond to PPIs. EGD is normal.
Esophageal manometry shows simultaneous contractions with high amplitude.
What is the most likely diagnosis?
A) Achalasia
B) Diffuse esophageal spasm
C) GERD
D) Scleroderma esophagus
Answer: B) Diffuse esophageal spasm
Rationale: Diffuse esophageal spasm is characterized by intermittent dysphagia
and chest pain with manometry showing simultaneous (non-peristaltic)
contractions of high amplitude. EGD is typically normal. This distinguishes it from
achalasia (absent peristalsis with impaired LES relaxation).
9. A patient with GERD develops dysphagia and odynophagia. EGD reveals a
white, plaque-like exudate in the distal esophagus. Biopsy shows fungal
hyphae and yeast. What is the most appropriate treatment?
