Anatomy
Blood supply to esophagus
Cervical: inferior thyroid artery
Thoracic: branches from the aorta (and bronchial artery branches)
Abdominal: left gastric and inferior phrenic
A patient presents to the emergency department after ingesting an ammonia-containing cleaning product.
Unique qualities of alkaline substances and their associated injuries include:
A. They tend to be bitter and cause immediate pain on ingestion
B. They produce an eschar
C. Less likely to form severe stricture and or cause motor dysfunction in patients who survive the initial injury as compared to acid ingestion
D. Increased esophageal and gastric injury in solid compounds as opposed to liquid compounds
E. Deeper penetration of the oropharynx and esophagus, leading to early perforation in the postingestion period
Alkaline caustic ingestions tend to be more severe than their acidic counterparts
A 40-year-old woman with a long-standing history of heartburn who is taking 20 mg/d of proton pump inhibitors undergoes endoscopy. Endoscopic biopsy at the distal esophagus reveals intestinal metaplasia with low-grade dysplasia. What is the best course of action?
A. Continue current treatment and repeat endoscopy in 3 years.
B. Recommend esophagectomy for dysplastic changes and high risk of adenocarcinoma.
C. Repeat surveillance endoscopy every 6 months and increase the dose of proton pump inhibitors.
D. Initiate treatment for Helicobacter pylori to limit progression of dysplasia.
E. Perform Nissen fundoplication and eliminate the need for further surveillance.
Patients with Barrett esophagus and low-grade dysplasia should be in an endoscopic surveillance program every 6 months to look for progression or malignancy.
A 46-year-old man presents to the emergency department with acute onset of chest pain after having an upper endoscopy earlier that day to evaluate his reflux disease. He is afebrile with a pulse rate of 78/min and blood pressure of 130/45 mm Hg. His laboratory studies are only remarkable for a WBC count of 16/μL. He has a CT angiogram of the chest to rule out a pulmonary embolism, which showed pneumomediastinum. He is admitted for observation and started on IV piperacillin/tazobactam and IV fluconazole. Which of the following is the most appropriate next step in the management of this patient?
A. immediate operative exploration
B. repeat esophagogastroduodenoscopy and placement of a stent
C. observation with serial complete blood counts
D. swallow esophagogram
E. chest x-ray and placement of chest tube
first with gastrograffin followed by dilute barium if no leak is seen with gastrograffin, then by full-strength barium if no leak is seen with dilute barium
A 70-year-old man with dysphagia of recent onset and a 30-lb weight loss in the past year presents to your office for evaluation. Workup demonstrates a T2N1M0 distal esophageal adenocarcinoma. What is the best predictor of long-term survival in this man?
A. Number of regional nodes involved
B. T stage
C. Necessity of neoadjuvant chemoradiotherapy
D. Size of the lesion at endoscopy
The extent of nodal involvement is the best predictor of long-term survival in patient devoid of systemic metastases
Killian's triangle and clinical significance
Between inferior constrictor and cricopharyngeus muscle
Weak spot for a pharyngoesophageal (Zenker’s) diverticulum
A 31-year-old man presents to the emergency department 1 hour after ingesting a bottle of drain cleaner in a suicide attempt. His pulse rate is 101/min, his blood pressure is 144/78 mm Hg, and his oxygen saturation is 98% on room air. He is complaining of chest pain and nausea. Which of the following is the next best step in the management of this patient?
A. nasogastric tube insertion and early intubation
B. CT scan of the chest and abdomen
C. administration of neutralizing agents
D. right video-assisted thoracoscopic irrigation and drainage
E. administration of glucocorticoids and nasogastric tube insertion
The initial workup of caustic esophageal injuries should include a CT scan of the chest and abdomen with IV and oral contrast in addition to early upper endoscopy (esophagogastroduodenoscopy) to define the extent of the injury.
A 65-year-old man with a BMI of 29 has failed medical therapy for gastrointestinal reflux disease (GERD). Manometry shows a weakened lower esophageal sphincter tone, impaired peristalsis, and a low mean esophageal length. Upper gastrointestinal series show regurgitation in the distal esophagus. After extensive dissection of the distal and mid esophagus, the gastroesophageal junction still cannot be brought 3 cm below the diaphragm without tension. The most appropriate next step in management includes
A. aborting the procedure and continuing with optimized medical therapy
B. magnetic sphincter augmentation
C. securing the esophagus to the diaphragm and Toupet fundoplication
D. Collis gastroplasty and Toupet fundoplication
E. Roux-en-Y gastric bypass
Shortened esophageal lengths are best treated with a Collis gastroplasty and, in the presence of abnormal manometric findings, a partial fundoplication.
A 54-year-old male had an EGD performed for evaluation of a hiatal hernia. Later that day, he comes to the ER with complaints of dysphagia. An UGI shows an esophageal perforation with a contained leak in the neck at the level of the cricopharyngeus. He is afebrile, and his vital signs are within normal limits. Which of the following is true concerning this patient's presentation?
A. He requires immediate nasogastric tube placement in the emergency department
B. He can be safely observed on intravenous antibiotics
C. He requires an immediate primary repair of his esophageal perforation
D. He requires CT guided drainage of the contained perforation
E. He requires esophageal diversion
Contained esophageal perforations in a stable patient can be treated with observation and antibiotics. Frequent clinical reassessment is needed.
Bonus points: not contained?
A 65-year-old man presents to the office with difficulty swallowing and a 30-lb weight loss over the past year. He has a 45-pack year history of smoking and drinks 6-10 beers every day after work. He undergoes upper endoscopy, which demonstrates the lesion in the image below. The mass is located 2 cm distal to the upper esophageal sphincter. It is consistent with T2N0 squamous cell cancer. PET/CT scan demonstrates no metastatic lesions. What is the best definitive therapy for this lesion?
A. esophagectomy alone
B. endoscopic resection
C. radiation therapy alone
D. neoadjuvant chemoradiation therapy followed by esophagectomy
E. definitive chemoradiation therapy
Squamous cell carcinoma of the proximal esophagus is primarily treated with chemoradiation.
During the creation of the gastric conduit in a transhiatal esophagectomy, which artery is the main blood supply to the conduit?
right gastroepiploic artery
A 5-year-old boy is brought to the emergency department after drinking drain cleaner he found under the sink. According to his mother, he drank only a sip, after which she made him spit it out and drink two glasses of water. On examination, the boy has normal vital signs, clear lungs to auscultation, and no abdominal pain. He is not vomiting, drooling, or exhibiting stridor. What is the appropriate next step in management?
A. Emergent endoscopy
B. ICU admission
C. Oral trial
D. CT of the chest/abdomen/pelvis
E. Discharge
Children with accidental alkali ingestion who were asymptomatic or with only vomiting/drooling had grade 1 injury at worst. It is now standard practice for children who fit this criteria to be given an oral trial with several hours of observation.
A 37-year-old obese man with a body mass index of 42 kg/m2 is being evaluated for heartburn and symptoms of gastroesophageal reflux disease. He is started on proton pump inhibitors; although the heartburn improves, he continues to have regurgitation and coughing spells. He is seeking a surgical intervention. What is the procedure of choice?
A. Laparoscopic Nissen fundoplication
B. Belsey Mark IV thoracic approach
C. Laparoscopic Roux-en-Y gastric bypass
D. Laparoscopic sleeve gastrectomy
E. Endoscopic fundoplication
Roux-en-Y gastric bypass would be most appropriate for this obese man with reflux and regurgitation because a small pouch is created with minimal acid production.
A female patient with is brought in by emergency medical services 1 week after undergoing endoscopic dilation of an esophageal stricture. On arrival, her temperature is 39 ºC, HR is in the 110s (beats/min) and BP is 100/60 mm Hg. CT scan shows mediastinal air and a large, loculated right pleural effusion. An esophagram confirms the diagnosis of esophageal perforation, and esophagoscopy shows a 10 cm x 4-cm defect on the right midesophagus, with a wide margin of dusky tissue and extensive fibrinous exudate. In addition to starting broad-spectrum antibiotics, how do you plan to proceed?
A. Esophageal stenting and right-sided chest tube placement
B. Endoluminal vacuum placement and right-sided chest tube placement
C. Transhiatal esophagectomy, spit fistula creation, and percutaneous endoscopic gastrostomy tube placement
D. Right posterolateral thoracotomy, esophagectomy with spit fistula creation, and J tube placement
E. Right posterolateral thoracotomy, double-layered primary repair of the esophageal perforation, pedicled muscle flap placement, and right-sided chest tube drainage
Right posterolateral thoracotomy, esophagectomy with spit fistula creation, and J tube placement
A 56-year-old otherwise healthy woman has an esophagogastroduodenoscopy for upper abdominal pain and is found to have adenocarcinoma involving the gastroesophageal junction and extending 1 cm onto the stomach. Endoscopic ultrasound demonstrates that the tumor invades into the adventitia and there are no suspicious lymph nodes. The remainder of her staging shows no evidence of distant disease. What is the best management for this patient?
A. Neoadjuvant chemoradiation and total gastrectomy
B. Neoadjuvant chemoradiation and transthoracic esophagogastrectomy
C. Neoadjuvant chemoradiation and proximal subtotal gastrectomy
D. Transhiatal esophagogastrectomy with adjuvant chemoradiation
E. Definitive chemoradiation
Siewert II, T3N0 esophageal adenocarcinoma of the gastroesophageal junction treated with esophagogastrectomy after neoadjuvant chemoradiation
Bonus points: Siewert classification for GE junction tumors and treatment
A 45-year-old woman presents to the office with a 3-month history of dysphagia. Manometry testing shows aperistalsis and a lower esophageal sphincter pressure of 20 mm Hg with a food bolus. Which of the following is true?
A. Diagnosis can be confirmed with a CT scan
B. Calcium channel blockers can provide long-term improvement of symptoms
C. The symptoms are due to injured ganglion cells
D. The patient will need a cricopharyngeal myotomy
E. An upper GI will have a corkscrew appearance
Achalasia is secondary to injured neuronal ganglion cells
A 20-year-old woman, a college student, presents to the emergency department after an apparent suicide attempt. She drank approximately 500 mL of an unknown liquid from a chemistry laboratory. She is speaking in complete sentences without respiratory distress and has mild epigastric discomfort. After establishment of airway patency and hemodynamic stability, as well as placement of intravenous access, which of the following is the next best management step?
A. Nasogastric tube insertion
B. Induction of emesis
C. Oral dilution with water
D. Glucocorticoid administration
E. Urgent endoscopy
Endoscopy should be performed as soon as possible after caustic ingestions, ideally within 24 hours, to assess the magnitude and extent of injury.
When considering patients for an anti-reflux operation secondary to GERD, which of the following is true?
A patient who has a DeMeester score of 40 on a pH probe study should be considered for a Nissen fundoplication.
B. All patients who have a sliding hiatal hernia should be considered candidates for a Nissen fundoplication.
C. Patients who do not respond well to proton-pump inhibitors have greater success after a Nissen fundoplication vs patients who do respond well to proton pump inhibitors.
D. A patient with untreated high-grade dysplasia of the gastroesophageal junction should undergo a Nissen fundoplication to prevent further progression of the disease.
E. A patient with GERD symptoms of hoarseness and cough will usually have greater success after a Nissen fundoplication vs a patient with classic heartburn.
Endoscopic findings of esophagitis, persistent symptoms of heartburn despite medical management, and non-compliance with medical therapy serve as indications for anti-reflux surgery.