ABSITE - ESOPHAGUS – QUESTIONS WITH
CORRECT ANSWERS
A 75-year-
old male presents to the clinic with a feeling of fullness in his throat and trouble swallowing. He comp
lains of a worsening cough and more recently, bad breath to the point he avoids going out in public.
What is the most appropriate first diagnostic test?
A. Plain chest x-ray
B. Barium esophagram
C. Upper endoscopy
D. Manometry
E. CT of the chest - CORRECT ANSWER -Barium esophagram
Correct.
This patient presents with classic symptoms of Zenker's diverticulum, which is most commonly found i
n elderly patients and is believed to be the result of loss of tissue elasticity and muscle tone associate
d with aging. It is found herniating into Killian's triangle, located at the junction of the hypopharynx an
d the esophagus. The most appropriate first diagnostic test would be a barium esophagram, especially
lateral views since it is usually found posteriorly alongside the esophagus. Upper endoscopy and man
ometry are not necessary in diagnosing Zenker's.
A 50-year-
old male presents to the ER with chest pain 6 hours aſter undergoing pneumatic dilation for achalasia.
A water-soluble contrast UGI demonstrates a small well-
contained perforation. The distal esophagus appears patent. The patient is hemodynamically stable. W
hat is the next best step in management?
A. Observe and attempt PO trial.
B. Admit, keep NPO and start broad-spectrum antibiotics.
C. Placement of a CT-guided mediastinal drain
D. Immediate operative debridement
E. Discharge patient with close follow-up. - CORRECT ANSWER -Admit, keep NPO and start broad-
spectrum antibiotics.
Correct.
Most iatrogenic esophageal perforations secondary to pneumatic dilation are small and well-
contained. The patient should be initially considered for non-
operative management with antibiotics and close monitoring based on the aforementioned UGI findin
,gs if the distal obstruction has been resolved and the patient remains hemodynamically stable. Develo
pment of concerning signs may ultimately warrant intervention such as CT-
guided drainage or operative management. Attempting PO trial or discharge would be inappropriate a
nd premature at this time.
A 35-year-
old male presents to the ER complaining of chest pain. He went out to dinner 2 nights ago and rapidly
developed abdominal cramps, emesis and diarrhea; however, he did not notice blood in his vomit or
stools. This morning he woke up with acute onset of 10/10 chest pain and described feeling lighthead
ed and dizzy. He denies any recent alcohol use. Current vital signs are: HR 120 bpm, BP 100/68 mmHg
, R 24/min and T 101.6°F. Which test is most likely to identify the diagnosis?
A. EKG
B. Flat plate and upright of the abdomen
C. Esophagram
D. Stool pathogens
E. Urea breath test - CORRECT ANSWER -Esophagram
Correct.
Thex correctx diagnosisx isxspontaneousx esophagealx perforation,xorxBoerhaavex syndrome.x Thex stemx ident
i
fiesx axrecentx episodex ofxfoodx poisoningx withx significantx emesis.x Althoughx thisx patientx doesn'tx drink,xa
lc
oholismx andx bingex drinkingx withx emesisxisx anotherxredx flagx forx esophagealx spontaneousx perforation.x
C
ontrastxesophagramx isx thex testx mostx likelyx tox identifyxthex diagnosis.xCTxscan,xalthoughx notx listed,x isx a
ls
ox helpful.x EKGx wouldx bex helpfulx tox identifyx ax cardiacxetiologyxsuchx asxMI,x butx inxourx patientxwouldx li
kel
yx justx showx sinusx tachycardia.x Abdominalx seriesxwouldx helpx diagnosex bowelxobstructionxorxpneumope
r
Ax 45-year-
itoneumx fromx ax hollowx viscusx perforation.x Stoolx pathogenx mayx bex positivexgivenx recentx gastroenteriti
oldxmalex presentsx tox thex ERx complainingx ofxnauseaxandx vomiting.xHex smellsxofxalcoholx andx notesx ax c
s;
ha
however,x thisx isx notxthex causex ofxdelayedx sepsis.x Ureax breathx testx isx usedx tox diagnosex H.x pylorixrelat
ngex inx emesisx fromx biliousxtox bloodyx acutelyx thisx evening.x Uponx furtherx questioning,x hex admitsx tox bi
ed
ng
tox pepticxulcerx disease.
ex drinkingx oſtenx tox thex pointx ofxvomiting.xHisx currentx vitalsx are:x HRx 110x bpm,x BPx 120/74x mmHg,x Rx 2
A.
2/xPepticx ulcerx disease
min x andx Tx 99.3°F.x Whatx isx thex likelyx causex ofx hisx symptoms?
B.x Esophageal x varices
C.x Esophagealx perforation
D.x Esophagealx cancer
,x
E.x Mallory-Weissx syndromex -x CORRECTx ANSWERx-Mallory-Weissx syndrome
Correct.
Thex patientx hasxMallory-
Weissx syndrome.x Fromx hisxhistory,x hex appearsx tox bex anx alcoholicxonxax recentx binge.x Althoughx thex diff
er
entialxforx upperx GIx bleedingx andx emesisx isx broad,x biliousx emesisx whichx acutelyx changesx tox bloodyx em
es
isx isx highlyx suggestivexofxaxMallory-
Weissx tear,x whichxoccursx atx thex junctionxofxthex esophagusx andx gastricx cardia.x Cancerx isx likelyx tox have
xa
morex indolentxobstructivexpresentation.xPerforationxoſtenx presentsx withx tachycardia,x leukocytosisx andx
fAx 42-year-
ever.
oldxotherwisex healthyx femalex wasx notedx tox havex persistentx UGIx bleedingx followingx anx episodexofxsev
er
ex vomiting.xEndoscopicxevaluationx notesx ax mucosalxtearx inx thexgastricxcardia.x Multiplex endoscopicx att
e
mptsx failx tox controlx thex bleeding.x Thex patientx isx nowx hemodynamicallyx unstable.x Whatx isx thex nextx st
A.
epxOctreotide
in
B.xxmanagement?
Continuousxprotonx pumpx inhibitor
C.x Repeatx attemptxatx endoscopicx electrocoagulation
D.x Angiographicx embolization
E.x Oversewingx lacerationxthroughx anx anteriorx gastrostomyx -
x CORRECTx ANSWERx -
Oversewingx lacerationxthroughx anx anteriorx gastrostomy
Correct.
Mallory-
Weissx tearsx arex oſtenx causedx byx forcefulx retchingxorxcoughing.x Similarx tox otherxsourcesxofxUGIx bleedi
ng
, initialxtreatmentxtypicallyxconsistsxofxnon-
operativex medicalx managementx andx endoscopicx maneuvers.x However,x inx casesxofxpersistentx bleedingx
a
ndx concurrentx hemodynamicx instability,x operativex interventionx isxwarranted.x Thex mucosalx tearx isx typic
a
llyx locatedx inx thexgastricx cardiax andx canx bex accessedx throughx anx anteriorx gastrostomy.x Continuedx med
ic
alx therapyxwouldx notx bex appropriatex atx thisx time.xAngiographicx embolizationx canx bex utilizedx inx casesx
w
Ax 1-year-
hen patients
oldxxchild x arex notx suitablex orx unwillingx tox undergox surgery.
x presentsx tox thex emergencyx roomx aſterx havingx swallowedx ax penny.x Atx whichx levelx ofx thex eso
ph
agusx isx thex coinx mostx likelyx tox becomex lodged?
A.xCervicalx esophagus
B.x Midxesophagus
CORRECT ANSWERS
A 75-year-
old male presents to the clinic with a feeling of fullness in his throat and trouble swallowing. He comp
lains of a worsening cough and more recently, bad breath to the point he avoids going out in public.
What is the most appropriate first diagnostic test?
A. Plain chest x-ray
B. Barium esophagram
C. Upper endoscopy
D. Manometry
E. CT of the chest - CORRECT ANSWER -Barium esophagram
Correct.
This patient presents with classic symptoms of Zenker's diverticulum, which is most commonly found i
n elderly patients and is believed to be the result of loss of tissue elasticity and muscle tone associate
d with aging. It is found herniating into Killian's triangle, located at the junction of the hypopharynx an
d the esophagus. The most appropriate first diagnostic test would be a barium esophagram, especially
lateral views since it is usually found posteriorly alongside the esophagus. Upper endoscopy and man
ometry are not necessary in diagnosing Zenker's.
A 50-year-
old male presents to the ER with chest pain 6 hours aſter undergoing pneumatic dilation for achalasia.
A water-soluble contrast UGI demonstrates a small well-
contained perforation. The distal esophagus appears patent. The patient is hemodynamically stable. W
hat is the next best step in management?
A. Observe and attempt PO trial.
B. Admit, keep NPO and start broad-spectrum antibiotics.
C. Placement of a CT-guided mediastinal drain
D. Immediate operative debridement
E. Discharge patient with close follow-up. - CORRECT ANSWER -Admit, keep NPO and start broad-
spectrum antibiotics.
Correct.
Most iatrogenic esophageal perforations secondary to pneumatic dilation are small and well-
contained. The patient should be initially considered for non-
operative management with antibiotics and close monitoring based on the aforementioned UGI findin
,gs if the distal obstruction has been resolved and the patient remains hemodynamically stable. Develo
pment of concerning signs may ultimately warrant intervention such as CT-
guided drainage or operative management. Attempting PO trial or discharge would be inappropriate a
nd premature at this time.
A 35-year-
old male presents to the ER complaining of chest pain. He went out to dinner 2 nights ago and rapidly
developed abdominal cramps, emesis and diarrhea; however, he did not notice blood in his vomit or
stools. This morning he woke up with acute onset of 10/10 chest pain and described feeling lighthead
ed and dizzy. He denies any recent alcohol use. Current vital signs are: HR 120 bpm, BP 100/68 mmHg
, R 24/min and T 101.6°F. Which test is most likely to identify the diagnosis?
A. EKG
B. Flat plate and upright of the abdomen
C. Esophagram
D. Stool pathogens
E. Urea breath test - CORRECT ANSWER -Esophagram
Correct.
Thex correctx diagnosisx isxspontaneousx esophagealx perforation,xorxBoerhaavex syndrome.x Thex stemx ident
i
fiesx axrecentx episodex ofxfoodx poisoningx withx significantx emesis.x Althoughx thisx patientx doesn'tx drink,xa
lc
oholismx andx bingex drinkingx withx emesisxisx anotherxredx flagx forx esophagealx spontaneousx perforation.x
C
ontrastxesophagramx isx thex testx mostx likelyx tox identifyxthex diagnosis.xCTxscan,xalthoughx notx listed,x isx a
ls
ox helpful.x EKGx wouldx bex helpfulx tox identifyx ax cardiacxetiologyxsuchx asxMI,x butx inxourx patientxwouldx li
kel
yx justx showx sinusx tachycardia.x Abdominalx seriesxwouldx helpx diagnosex bowelxobstructionxorxpneumope
r
Ax 45-year-
itoneumx fromx ax hollowx viscusx perforation.x Stoolx pathogenx mayx bex positivexgivenx recentx gastroenteriti
oldxmalex presentsx tox thex ERx complainingx ofxnauseaxandx vomiting.xHex smellsxofxalcoholx andx notesx ax c
s;
ha
however,x thisx isx notxthex causex ofxdelayedx sepsis.x Ureax breathx testx isx usedx tox diagnosex H.x pylorixrelat
ngex inx emesisx fromx biliousxtox bloodyx acutelyx thisx evening.x Uponx furtherx questioning,x hex admitsx tox bi
ed
ng
tox pepticxulcerx disease.
ex drinkingx oſtenx tox thex pointx ofxvomiting.xHisx currentx vitalsx are:x HRx 110x bpm,x BPx 120/74x mmHg,x Rx 2
A.
2/xPepticx ulcerx disease
min x andx Tx 99.3°F.x Whatx isx thex likelyx causex ofx hisx symptoms?
B.x Esophageal x varices
C.x Esophagealx perforation
D.x Esophagealx cancer
,x
E.x Mallory-Weissx syndromex -x CORRECTx ANSWERx-Mallory-Weissx syndrome
Correct.
Thex patientx hasxMallory-
Weissx syndrome.x Fromx hisxhistory,x hex appearsx tox bex anx alcoholicxonxax recentx binge.x Althoughx thex diff
er
entialxforx upperx GIx bleedingx andx emesisx isx broad,x biliousx emesisx whichx acutelyx changesx tox bloodyx em
es
isx isx highlyx suggestivexofxaxMallory-
Weissx tear,x whichxoccursx atx thex junctionxofxthex esophagusx andx gastricx cardia.x Cancerx isx likelyx tox have
xa
morex indolentxobstructivexpresentation.xPerforationxoſtenx presentsx withx tachycardia,x leukocytosisx andx
fAx 42-year-
ever.
oldxotherwisex healthyx femalex wasx notedx tox havex persistentx UGIx bleedingx followingx anx episodexofxsev
er
ex vomiting.xEndoscopicxevaluationx notesx ax mucosalxtearx inx thexgastricxcardia.x Multiplex endoscopicx att
e
mptsx failx tox controlx thex bleeding.x Thex patientx isx nowx hemodynamicallyx unstable.x Whatx isx thex nextx st
A.
epxOctreotide
in
B.xxmanagement?
Continuousxprotonx pumpx inhibitor
C.x Repeatx attemptxatx endoscopicx electrocoagulation
D.x Angiographicx embolization
E.x Oversewingx lacerationxthroughx anx anteriorx gastrostomyx -
x CORRECTx ANSWERx -
Oversewingx lacerationxthroughx anx anteriorx gastrostomy
Correct.
Mallory-
Weissx tearsx arex oſtenx causedx byx forcefulx retchingxorxcoughing.x Similarx tox otherxsourcesxofxUGIx bleedi
ng
, initialxtreatmentxtypicallyxconsistsxofxnon-
operativex medicalx managementx andx endoscopicx maneuvers.x However,x inx casesxofxpersistentx bleedingx
a
ndx concurrentx hemodynamicx instability,x operativex interventionx isxwarranted.x Thex mucosalx tearx isx typic
a
llyx locatedx inx thexgastricx cardiax andx canx bex accessedx throughx anx anteriorx gastrostomy.x Continuedx med
ic
alx therapyxwouldx notx bex appropriatex atx thisx time.xAngiographicx embolizationx canx bex utilizedx inx casesx
w
Ax 1-year-
hen patients
oldxxchild x arex notx suitablex orx unwillingx tox undergox surgery.
x presentsx tox thex emergencyx roomx aſterx havingx swallowedx ax penny.x Atx whichx levelx ofx thex eso
ph
agusx isx thex coinx mostx likelyx tox becomex lodged?
A.xCervicalx esophagus
B.x Midxesophagus
