Q21) Which one of the following is not a management option in early esophageal cancer?
a) Photodynamic therapy
b) Endoscopic Mucosal resection
c) Argon plasma coagulation
d) Esophagectomy
21 d Esophagectomy
There is a recent term Endoscopically suspected Esophageal metaplasia (ESEM) seen with white light high resolution endoscopy. Management is PPI and repeat evaluation after 6-12 months
Once Barrett's esophagus is diagnosed, the further management depends on weather its a low grade or high grade dysplasia.
No dysplasia and barrett's segment < 3 cm - Endoscopic surveillance 5 yearsNo dysplasia and barrett's segment > 3 cm - 3 year surveillance with four quadrant biopsy every 2 cm
i) age younger than 30 years at the time of Barrett's diagnosis
ii) a family history of Barrett's esophagus or esophageal cancer,
iii) a segment of circumferential Barrett's esophagus greater than 6 cm
Endoscopic ablative therapy can be considered
Dysplasia and Invasive carcinoma
No submucosal invasion - EMR followed by ablative management
T1b or more (submucosal invasion) -Esophagectomy
EMR, PDT and APC can be done for T1a lesion
Q22) Which of the following is the least common symptom of nutcracker esophagus?
a) Pain in chest
b) Dysphagia
c) Odynophagia
d) Regurgitation
22) d
Nutcracker esophagus is a hyper contractile disorder of the esophagus in which there is excessive contractility of the esophagus. There are high amplitude peristaltic contractions in the body of esophagus.
It is the most common motility disorder of the esophagus.
It can occur in all age groups and is of equal distribution in both sex.
Nutcracker esophagus symptoms
Chest pain
Dysphagia
Painful deglutition (Odynophagia)
Acording to the Chicago classification
There is subjective complaint of chest pain with at least one swallow showing a distal contractile integral greater than 8000 mm Hg with single or multipeaked contractions on HRM. The LES pressure is normal, and relaxation occurs with each wet swallow
Q23. All are true about Nissen's fundoplication except?
a) It is a 360 degree fundoplication
b) Gas bloat syndrome is a common complication
c) Nissen's fundoplication can be done by both thoracic and abdominal approach
d) Usually three sutures are taken to hold the wrap
23. c
Nissen fundoplication is only an abdominal procedure in which total fundoplication is done. it is a 360 degree wrap. It might have short term dysphagia but is durable in the long run.
Gas bloat syndrome is a very common complication in which belching is not possible. If gas bloat is excessive and disabling conversion to a partial fundoplication is done.
Q24 ) Management of esophagus perforation after 96 hours in a 40 year old patient with pulse 110/min and BP 110/80 Best option?
a) Antibiotics and drainage of left pleural effusion
b) Primary repair of esophagus
c) Esophagectomy and gastric pull up
d) Cervical Esophagus diversion with gastrostomy
24. d
The golden period of repair for esophagus perforation is 24-48 hours. after 48 hours there starts contamination of mediastinal structures with signs of systemic sepsis.
Primary repair principles -
With in 24-48 hours
Expose the defect clearly with myotomy above and below
Closure of mucosa, muscle and with pedicled flap if available
Esophagus diversion principles
After mediastinal contamination
MOre than 48 hours
Esophagus resection
Associated diseases such as achalasia, reflux strictures, malignancy
Conservative
Cameron criteria
Early diagnosis intramural perforation
Transmural perforation of mediastinum or neck with free drainage back to the esophagus on esophagogram
Absence of any other esophagus disease
No symptoms/Sepsis
Ref: Shackelford - 482
Q 25 Oropharyngeal dysphagia false is A. Nasal twang in voice, ptosis B. Treatment is most often not satisfactory if conservative C. Associated with myesthenia gravis and Parkinsonism D. Water brasch and regurgitation presentation
25 d)
Oropharyngeal dysphagia is characterized by difficulty in transferring food out of the mouth into the esophagus,
nasal regurgitation, aspiration, or any combination of these symptoms.
Poor coordination plus hypopharyngeal stasis results in laryngeal and tracheal aspiration
Cricopharyngeal myotomy is a recognized treatment of patients with dysfunction of the pharyngoesophageal
junction secondary to neurologic conditions. Conservative treatment fails
Water braasch and Regurgitation are seen in GERD and not in this disease