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.
Thec correctc diagnosisc isc spontaneousc esophagealc perforation,corcBoerhaavec syndrome.c Thec stemc identi
fiesc ac recentc episodec ofc foodc poisoningc withc significantc emesis.c Althoughc thisc patientc doesn'tc drink,c alc
oholismc andc bingec drinkingc withc emesisc isc anotherc redc flagc forc esophagealc spontaneousc perforation.c C
ontrastc esophagramc isc thec testc mostc likelyc toc identifyc thec diagnosis.c CTc scan,calthoughc notc listed,c isc als
oc helpful.c EKGc wouldc bec helpfulc toc identifyc ac cardiacc etiologyc suchc asc MI,c butc inc ourc patientc wouldc like
l
yc justc showc sinusc tachycardia.c Abdominalc seriesc wouldc helpc diagnosec bowelcobstructioncorc pneumoper
itoneumc fromc ac hollowc viscusc perforation.c Stoolc pathogenc mayc bec positivecgivenc recentc gastroenteritis;
however,c thisc isc notc thec causec ofc delayedc sepsis.c Ureac breathc testc isc usedc toc diagnosec H.c pyloric relate
d
toc pepticc ulcerc disease.
Ac 45-year-
oldc malec presentsc toc thec ERc complainingc ofc nauseac andc vomiting.c Hec smellscofc alcoholc andc notesc ac ch
a
ngec inc emesisc fromc biliousc toc bloodyc acutelyc thisc evening.c Uponc furtherc questioning,c hec admitsc toc bin
g
ec drinkingc oſtenc toc thec pointc ofc vomiting.c Hisc currentc vitalsc are:c HRc 110c bpm,c BPc 120/74c mmHg,c Rc 22/
A.
minc Pepticc ulcerc disease
c andc Tc 99.3°F.c Whatc isc thec likelyc causec ofc hisc symptoms?
B.c Esophagealc varices
C.c Esophagealc perforation
D.c Esophagealc cancer
,c
E.c Mallory-Weissc syndromec -c CORRECTc ANSWERc-Mallory-Weissc syndrome
Correct.
Thec patientc hascMallory-
Weissc syndrome.c Fromc hisc history,c hec appearsc toc bec anc alcoholicconcac recentc binge.c Althoughc thec diffe
r
entialc forc upperc GIc bleedingc andc emesisc isc broad,c biliousc emesisc whichc acutelyc changesc toc bloodyc eme
s
isc isc highlyc suggestivecofc ac Mallory-
Weissc tear,c whichcoccursc atc thec junctioncofc thec esophagusc andc gastricc cardia.c Cancerc isc likelyc toc havec a
morec indolentc obstructivec presentation.c Perforationcoſtenc presentsc withc tachycardia,c leukocytosisc andc f
ever.
Ac 42-year-
oldc otherwisec healthyc femalec wasc notedc toc havec persistentc UGIc bleedingc followingc anc episodecofc sever
ec vomiting.c Endoscopicc evaluationc notesc ac mucosalctearc inc thecgastricccardia.c Multiplec endoscopicc atte
mptsc failc toc controlc thec bleeding.c Thec patientc isc nowc hemodynamicallyc unstable.c Whatc isc thec nextc ste
p
inc management?
A.c Octreotide
B.c Continuousc protonc pumpc inhibitor
C.c Repeatc attemptcatc endoscopicc electrocoagulation
D.c Angiographicc embolization
E.c Oversewingc lacerationc throughc anc anteriorc gastrostomyc -c CORRECTc ANSWERc -
Oversewingc lacerationc throughc anc anteriorc gastrostomy
Correct.
Mallory-
Weissc tearsc arec oſtenc causedc byc forcefulc retchingcorccoughing.c Similarc toc otherc sourcesc ofc UGIc bleedin
g, initialc treatmentc typicallyc consistsc ofcnon-
operativec medicalc managementc andc endoscopicc maneuvers.c However,c inc casescofc persistentc bleedingc a
ndc concurrentc hemodynamicc instability,c operativec interventionc iscwarranted.c Thec mucosalc tearc isc typica
llyc locatedc inc thec gastricc cardiac andc canc bec accessedc throughc anc anteriorc gastrostomy.c Continuedc medi
c
alc therapyc wouldc notc bec appropriatec atc thisc time.c Angiographicc embolizationc canc bec utilizedc inc casesc w
henc patientsc arec notc suitablec orc unwillingc toc undergoc surgery.
Ac 1-year-
oldc childc presentsc toc thecemergencyc roomc aſterc havingc swallowedc ac penny.c Atc whichc levelcofcthec esop
h
agusc isc thec coinc mostc likelyc toc becomec lodged?
A.c Cervicalc esophagus
B.c Midc esophagus
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.
Thec correctc diagnosisc isc spontaneousc esophagealc perforation,corcBoerhaavec syndrome.c Thec stemc identi
fiesc ac recentc episodec ofc foodc poisoningc withc significantc emesis.c Althoughc thisc patientc doesn'tc drink,c alc
oholismc andc bingec drinkingc withc emesisc isc anotherc redc flagc forc esophagealc spontaneousc perforation.c C
ontrastc esophagramc isc thec testc mostc likelyc toc identifyc thec diagnosis.c CTc scan,calthoughc notc listed,c isc als
oc helpful.c EKGc wouldc bec helpfulc toc identifyc ac cardiacc etiologyc suchc asc MI,c butc inc ourc patientc wouldc like
l
yc justc showc sinusc tachycardia.c Abdominalc seriesc wouldc helpc diagnosec bowelcobstructioncorc pneumoper
itoneumc fromc ac hollowc viscusc perforation.c Stoolc pathogenc mayc bec positivecgivenc recentc gastroenteritis;
however,c thisc isc notc thec causec ofc delayedc sepsis.c Ureac breathc testc isc usedc toc diagnosec H.c pyloric relate
d
toc pepticc ulcerc disease.
Ac 45-year-
oldc malec presentsc toc thec ERc complainingc ofc nauseac andc vomiting.c Hec smellscofc alcoholc andc notesc ac ch
a
ngec inc emesisc fromc biliousc toc bloodyc acutelyc thisc evening.c Uponc furtherc questioning,c hec admitsc toc bin
g
ec drinkingc oſtenc toc thec pointc ofc vomiting.c Hisc currentc vitalsc are:c HRc 110c bpm,c BPc 120/74c mmHg,c Rc 22/
A.
minc Pepticc ulcerc disease
c andc Tc 99.3°F.c Whatc isc thec likelyc causec ofc hisc symptoms?
B.c Esophagealc varices
C.c Esophagealc perforation
D.c Esophagealc cancer
,c
E.c Mallory-Weissc syndromec -c CORRECTc ANSWERc-Mallory-Weissc syndrome
Correct.
Thec patientc hascMallory-
Weissc syndrome.c Fromc hisc history,c hec appearsc toc bec anc alcoholicconcac recentc binge.c Althoughc thec diffe
r
entialc forc upperc GIc bleedingc andc emesisc isc broad,c biliousc emesisc whichc acutelyc changesc toc bloodyc eme
s
isc isc highlyc suggestivecofc ac Mallory-
Weissc tear,c whichcoccursc atc thec junctioncofc thec esophagusc andc gastricc cardia.c Cancerc isc likelyc toc havec a
morec indolentc obstructivec presentation.c Perforationcoſtenc presentsc withc tachycardia,c leukocytosisc andc f
ever.
Ac 42-year-
oldc otherwisec healthyc femalec wasc notedc toc havec persistentc UGIc bleedingc followingc anc episodecofc sever
ec vomiting.c Endoscopicc evaluationc notesc ac mucosalctearc inc thecgastricccardia.c Multiplec endoscopicc atte
mptsc failc toc controlc thec bleeding.c Thec patientc isc nowc hemodynamicallyc unstable.c Whatc isc thec nextc ste
p
inc management?
A.c Octreotide
B.c Continuousc protonc pumpc inhibitor
C.c Repeatc attemptcatc endoscopicc electrocoagulation
D.c Angiographicc embolization
E.c Oversewingc lacerationc throughc anc anteriorc gastrostomyc -c CORRECTc ANSWERc -
Oversewingc lacerationc throughc anc anteriorc gastrostomy
Correct.
Mallory-
Weissc tearsc arec oſtenc causedc byc forcefulc retchingcorccoughing.c Similarc toc otherc sourcesc ofc UGIc bleedin
g, initialc treatmentc typicallyc consistsc ofcnon-
operativec medicalc managementc andc endoscopicc maneuvers.c However,c inc casescofc persistentc bleedingc a
ndc concurrentc hemodynamicc instability,c operativec interventionc iscwarranted.c Thec mucosalc tearc isc typica
llyc locatedc inc thec gastricc cardiac andc canc bec accessedc throughc anc anteriorc gastrostomy.c Continuedc medi
c
alc therapyc wouldc notc bec appropriatec atc thisc time.c Angiographicc embolizationc canc bec utilizedc inc casesc w
henc patientsc arec notc suitablec orc unwillingc toc undergoc surgery.
Ac 1-year-
oldc childc presentsc toc thecemergencyc roomc aſterc havingc swallowedc ac penny.c Atc whichc levelcofcthec esop
h
agusc isc thec coinc mostc likelyc toc becomec lodged?
A.c Cervicalc esophagus
B.c Midc esophagus
