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.
Thez correctz diagnosisz iszspontaneousz esophagealz perforation,zorzBoerhaavez syndrome.z Thez stemz identi
fiesz azrecentz episodez ofzfoodz poisoningz withz significantz emesis.z Althoughz thisz patientz doesn'tz drink,zalc
oholismz andz bingez drinkingz withz emesiszisz anotherz redz flagz forz esophagealz spontaneousz perforation.z C
ontrastz esophagramz isz thez testz mostz likelyz toz identifyzthez diagnosis.zCTzscan,z althoughz notz listed,z isz als
oz helpful.z EKGz wouldz bez helpfulz toz identifyz az cardiaczetiologyzsuchz aszMI,z butz inzourz patientz wouldz like
l
yz justz showz sinusz tachycardia.z Abdominalz seriesz wouldz helpz diagnosez bowelzobstructionzorzpneumoper
itoneumz fromz az hollowz viscusz perforation.z Stoolz pathogenz mayz bez positivezgivenz recentz gastroenteritis;
however,z thisz isz notzthez causez ofzdelayedz sepsis.z Ureaz breathz testz isz usedz toz diagnosez H.z pylorizrelate
d
toz pepticzulcerz disease.
Az 45-year-
oldzmalez presentsz toz thez ERz complainingz ofznauseazandz vomiting.zHez smellszofzalcoholz andz notesz az ch
a
ngez inz emesisz fromz biliousztoz bloodyz acutelyz thisz evening.z Uponz furtherz questioning,z hez admitsz toz bin
g
ez drinkingz oſtenz toz thez pointz ofzvomiting.zHisz currentz vitalsz are:z HRz 110z bpm,z BPz 120/74z mmHg,z Rz 22/
A.
minz Pepticz ulcerz disease
z andz Tz 99.3°F.z Whatz isz thez likelyz causez ofz hisz symptoms?
B.z Esophagealz varices
C.z Esophagealz perforation
D.z Esophagealz cancer
,z
E.z Mallory-Weissz syndromez -z CORRECTz ANSWERz-Mallory-Weissz syndrome
Correct.
Thez patientz haszMallory-
Weissz syndrome.z Fromz hiszhistory,z hez appearsz toz bez anz alcoholiczonzaz recentzbinge.z Althoughz thez diffe
r
entialzforz upperz GIz bleedingz andz emesisz isz broad,z biliousz emesisz whichz acutelyz changesz toz bloodyz eme
s
isz isz highlyz suggestivezofzazMallory-
Weissz tear,z whichzoccursz atz thez junctionzofzthez esophagusz andz gastricz cardia.zCancerz isz likelyz toz havez a
morez indolentz obstructivezpresentation.zPerforationzoſtenz presentsz withz tachycardia,z leukocytosisz andz f
ever.
Az 42-year-
oldzotherwisez healthyz femalez wasz notedz toz havez persistentz UGIz bleedingz followingz anz episodezofzsever
ez vomiting.zEndoscopicz evaluationz notesz az mucosalztearz inz thezgastriczcardia.z Multiplez endoscopicz atte
mptsz failz toz controlz thez bleeding.z Thez patientz isz nowz hemodynamicallyz unstable.z Whatz isz thez nextz ste
p
inz management?
A.zOctreotide
B.z Continuousz protonz pumpz inhibitor
C.z Repeatz attemptzatz endoscopicz electrocoagulation
D.z Angiographicz embolization
E.z Oversewingz lacerationzthroughz anz anteriorz gastrostomyz -z CORRECTz ANSWERz -
Oversewingz lacerationz throughz anz anteriorz gastrostomy
Correct.
Mallory-
Weissz tearsz arez oſtenz causedz byz forcefulz retchingzorzcoughing.z Similarz toz otherzsourcesz ofzUGIz bleedin
g, initialztreatmentz typicallyz consistszofznon-
operativez medicalzmanagementz andz endoscopicz maneuvers.z However,z inz caseszofzpersistentz bleedingz a
ndz concurrentz hemodynamicz instability,z operativez interventionz iszwarranted.z Thez mucosalz tearz isz typica
llyz locatedz inz thezgastricz cardiaz andz canz bez accessedz throughz anz anteriorz gastrostomy.z Continuedz medi
c
alz therapyz wouldz notz bez appropriatez atz thisz time.zAngiographicz embolizationz canz bez utilizedz inz casesz w
henz patientsz arez notz suitablez orzunwillingz toz undergoz surgery.
Az 1-year-
oldzchildz presentsz toz thezemergencyz roomz aſterz havingz swallowedz az penny.z Atz whichz levelzofzthezesop
h
agusz isz thez coinz mostz likelyz toz becomez lodged?
A.zCervicalz esophagus
B.z Midzesophagus
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.
Thez correctz diagnosisz iszspontaneousz esophagealz perforation,zorzBoerhaavez syndrome.z Thez stemz identi
fiesz azrecentz episodez ofzfoodz poisoningz withz significantz emesis.z Althoughz thisz patientz doesn'tz drink,zalc
oholismz andz bingez drinkingz withz emesiszisz anotherz redz flagz forz esophagealz spontaneousz perforation.z C
ontrastz esophagramz isz thez testz mostz likelyz toz identifyzthez diagnosis.zCTzscan,z althoughz notz listed,z isz als
oz helpful.z EKGz wouldz bez helpfulz toz identifyz az cardiaczetiologyzsuchz aszMI,z butz inzourz patientz wouldz like
l
yz justz showz sinusz tachycardia.z Abdominalz seriesz wouldz helpz diagnosez bowelzobstructionzorzpneumoper
itoneumz fromz az hollowz viscusz perforation.z Stoolz pathogenz mayz bez positivezgivenz recentz gastroenteritis;
however,z thisz isz notzthez causez ofzdelayedz sepsis.z Ureaz breathz testz isz usedz toz diagnosez H.z pylorizrelate
d
toz pepticzulcerz disease.
Az 45-year-
oldzmalez presentsz toz thez ERz complainingz ofznauseazandz vomiting.zHez smellszofzalcoholz andz notesz az ch
a
ngez inz emesisz fromz biliousztoz bloodyz acutelyz thisz evening.z Uponz furtherz questioning,z hez admitsz toz bin
g
ez drinkingz oſtenz toz thez pointz ofzvomiting.zHisz currentz vitalsz are:z HRz 110z bpm,z BPz 120/74z mmHg,z Rz 22/
A.
minz Pepticz ulcerz disease
z andz Tz 99.3°F.z Whatz isz thez likelyz causez ofz hisz symptoms?
B.z Esophagealz varices
C.z Esophagealz perforation
D.z Esophagealz cancer
,z
E.z Mallory-Weissz syndromez -z CORRECTz ANSWERz-Mallory-Weissz syndrome
Correct.
Thez patientz haszMallory-
Weissz syndrome.z Fromz hiszhistory,z hez appearsz toz bez anz alcoholiczonzaz recentzbinge.z Althoughz thez diffe
r
entialzforz upperz GIz bleedingz andz emesisz isz broad,z biliousz emesisz whichz acutelyz changesz toz bloodyz eme
s
isz isz highlyz suggestivezofzazMallory-
Weissz tear,z whichzoccursz atz thez junctionzofzthez esophagusz andz gastricz cardia.zCancerz isz likelyz toz havez a
morez indolentz obstructivezpresentation.zPerforationzoſtenz presentsz withz tachycardia,z leukocytosisz andz f
ever.
Az 42-year-
oldzotherwisez healthyz femalez wasz notedz toz havez persistentz UGIz bleedingz followingz anz episodezofzsever
ez vomiting.zEndoscopicz evaluationz notesz az mucosalztearz inz thezgastriczcardia.z Multiplez endoscopicz atte
mptsz failz toz controlz thez bleeding.z Thez patientz isz nowz hemodynamicallyz unstable.z Whatz isz thez nextz ste
p
inz management?
A.zOctreotide
B.z Continuousz protonz pumpz inhibitor
C.z Repeatz attemptzatz endoscopicz electrocoagulation
D.z Angiographicz embolization
E.z Oversewingz lacerationzthroughz anz anteriorz gastrostomyz -z CORRECTz ANSWERz -
Oversewingz lacerationz throughz anz anteriorz gastrostomy
Correct.
Mallory-
Weissz tearsz arez oſtenz causedz byz forcefulz retchingzorzcoughing.z Similarz toz otherzsourcesz ofzUGIz bleedin
g, initialztreatmentz typicallyz consistszofznon-
operativez medicalzmanagementz andz endoscopicz maneuvers.z However,z inz caseszofzpersistentz bleedingz a
ndz concurrentz hemodynamicz instability,z operativez interventionz iszwarranted.z Thez mucosalz tearz isz typica
llyz locatedz inz thezgastricz cardiaz andz canz bez accessedz throughz anz anteriorz gastrostomy.z Continuedz medi
c
alz therapyz wouldz notz bez appropriatez atz thisz time.zAngiographicz embolizationz canz bez utilizedz inz casesz w
henz patientsz arez notz suitablez orzunwillingz toz undergoz surgery.
Az 1-year-
oldzchildz presentsz toz thezemergencyz roomz aſterz havingz swallowedz az penny.z Atz whichz levelzofzthezesop
h
agusz isz thez coinz mostz likelyz toz becomez lodged?
A.zCervicalz esophagus
B.z Midzesophagus
