Prometric GIT QUESTIONS

‫سؤال يف ساعتي بدايه من ال‬100

ESOPHAUS TO ANUS
(Slesinger 9, 10)

#FDA approved effective drug for ttt of GERD is :

• Metronidazole
• Baclofen
• Metoclopramide
• PPI
• Cisapride
# FDA approved prokinetic drug for treatment of GERD is:
• Metoclopramide
• Itopride
• Domperidone
•Cisapride
#Drugs that decrease intermittent lower esophageal sphincter relaxation(TLESR ) is
• Baclofen
• Cisapride
• Itopride
• Metoclopramide
#Regarding lower esophageal sphincter, intermittent relaxation >> Occurs with peristalsis
##A 50-year-old African American woman has rheumatoid arthritis, class IV ischemic
cardiomyopathy, and rheumatoid restrictive pulmonary disease requiring nocturnal oxygen
supplementation. She informs her rheumatologist that her weekly heartburn and rare
nocturnal regurgitation of 20 years’ duration have worsened over the past 2 months. She has
new nonspecific substernal chest pain with mild odynophagia(i.e no regurgitation or
eructation-history of BA). She states that she does not have dysphagia, impaction, or
unintentional weight loss. She is a nonsmoker(I.E NO ALARM SYMPTOMS). She has taken
famotidine(Antiacid) at bedtime for 10 years. No changes have been found in her cardiac
status. Her rheumatologist refers her to you. She has never had EGD. You recommend:
a. Upper gastrointestinal barium swallow b. Esophageal capsule study
b. EGD d. Empiric treatment with a PPI e. Surgical consultation
‫الن‬GERD>>Empiric treatment with a PPI
#DHA#25 years old male c/o heart burn,retrosternal chest pain,,regurgitation,foul acidic
sensation in the mouth consistent with GERD,no alarm symptoms. The nexet step is :
-Start PPI therapy -24 hours PH monitoring –UEG -Antiacids
# Pnt c/o dyspepsia.no other symptons, trial of PPI for 2 weeks. The patient is improved . what
is the nexet : - Compelet ppi -EGD -No further ttt
#DDSEP 7/17#Which of the following studies has the highest sensitivity for the initial diagnosis
of GERD presenting with typical symptoms of heart- burn and water brash?
A. Barium swallow
B. Empiric omeprazole
C. Wireless pH monitoring
D. pH-impedance monitoring
E. Upper endoscopy
The proton pump inhibitor test has a sensitivity of 78% and specificity of 54% for the diag-
nosis of GERD in the presence of typical reflux symptoms. This is cheap and simple, and is the
first therapeutic maneuver in this setting.
#Drugs that increase reflux esophagitis
• ASA
• Ranitidine
• Theophylline
• Amoxycilline
#Pnt c/o retrosternal soreness , regurgitation , mild asthma and decreased integrated residual
esophageal pressure . Diagnosis is:
• Achalasia(‫عال‬
‫بيكون ي‬Residual pressure)
• GERD
• Scleroderma ???
# 55 years old Pnt c/o heart burn(acid taste) since 15 years .EGD:mild erythema with irregular
Z line at GEJ, no alarm symptoms(i.e clinically consistent with GERD)‫هنالف‬
‫ي‬ ‫ >>>>>>> ي‬Basal cell
‫يعن‬
hyperplasia, protrusion of rete peg .the next step is : -PPI -EGD -Barium swallow 24
hours PH monitoring
## 4. A 58-year-old man underwent an OGD for investigation of reflux symptoms.
Macroscopically he was found to have an area suggestive
of Barrett’s oesophagus. This was biopsied and his histology report was returned to you.
Which of the following histological features best supports the endoscopic diagnosis of
Barrett’s oesophagus with no dysplasia>> Intestinal metaplastic glandular mucosa with
adjacent oesophageal ducts .
#Which number of eosinophils to diagnose eosinophilic infiltration?#
• 5
• 10
• 12
• 20
‫محمد عزيز‬/‫د‬## ‫بيج سؤال بس بصيغه تانيه بيقول‬
‫ي‬
Least number of esinophils in biopsy /HPF required to diagnose abnormal esinophilic mucosal
infiltration is >>15
#A 34-year-old man was seen in GI clinic because of 4 year history of dysphagia, primarily for
solids and heartburn 3-4 times a week. No history of anorexia, weight loss or food impaction.
An endoscopy was performed and the patient was found to have furrows and multiple rings.
Biopsies revealed more than 15 eosinophils per high power field. What would be the best
therapeutic approach in this patient?
A. Endoscopic dilation followed by topical steroid treatment
B. Food elimination protocol
C. Lifestyle modifications only because the patient has not lost weight
D. Topical steroid treatment followed by esophageal dilation
E. PPI treatment>> In patients with combined presentation of eosinophilic esophagitis and
GERD, the initial therapeutic goal is to focus on GERD. If a PPI improves patient’s heartburn
but has no impact on patient’s dysphagia than other therapeutic approaches should be
considered.
#Acase of cancer esophagus established after biopsy . the first line of investig. is >
PET > ‫ ثم‬CT>‫ ثم‬EUS
#MRCP Q BANK#Which one of the following is not associated with oesophageal cancer?
Achalasia Smoking Gastro-oesophageal reflux disease Helicobacter pylori Alcohol
Helicobacter pylori may actually be protective against oesophageal cancer
#GERD not responding to PPI, cardiology is normal, EGD is free, what to do? ‫ محمد عزيز‬/‫د‬#
• TCA Ambulatory pH monitoring Repeat endoscopy
#Golden standard for GERD#>>Ambulatory pH monitoring
#MRCP Q BANK#Which one of the following investigations is considered the gold standard for
the diagnosis of gastro-oesophageal reflux disease?
- Endoscopy -24hr oesophageal pH monitoring -Oesophageal manometry
-Barium swallow - CT thorax
24hr oesophageal pH monitoring is gold standard investigation in GORD
#MRCP Q BANK#A 59-year-old woman presents with dysphagia. There is no history of
heartburn, weight loss or change in bowel habit. During endoscopy there is some difficulty
passing through the lower oesophageal sphincter but no other abnormality is noted. Which
one of the following tests is most likely to reveal the diagnosis? Oesophageal biopsy
Oesophageal manometry Plain chest x-ray Endoscopy ultrasound CT thorax

The gold standard test for achalasia is oesophageal manometry

#Which of the following is risk factor for esophageal squamous cell carcinoma
• Barrett’s esophagus Smoking Obesity
#MRCP Q BANK#Which one of the following is most associated with oesophageal cancer? -
Coeliac disease -Hypothyroidism -Crohn's disease
- Addison's disease -Ulcerative colitis
Oesophageal cancer Until recent times oesophageal cancer was most commonly due to a
squamous cell carcinoma but the incidence of adenocarcinoma is rising rapidly.
Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to
develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett's.
Risk factors -smoking -alcohol -GORD -Barrett's oesophagus - achalasia -Plummer-Vinson
syndrome -squamous cell carcinoma is also linked to diets rich in nitrosamines -rare: coeliac
disease, scleroderma
#Best of five241# A 69-year-old man with known Barrett’s oesophagus attends for a
surveillance gastroscopy. He was admitted by an endoscopy nurse who raised several
concerns. Which of the following is the most important risk factor for sedation-related
complications?
A. Diabetes mellitus
B. Diuretic usage
C. Hypokalemia
D. Obesity
E. Recent hip replacement
#Most common skin disorder related to Barrett’s esophagus
• Pyoderma gangrenosum
• Erythema
• Tylosis
#‫ كلينيك‬During an endoscopic examination to evaluate diarrhea in a 63-year-old man, mild Los
Angeles Classification System Grade A reflux esophagitis, small hiatal hernia, and a 2-cm
segment of Barrett’s esophagus with low grade dysplasia were diagnosed. He is referred to
you for management. He has researched Barrett’s esophagus on the Internet and is very
unhappy with the diagnosis of a premalignant disorder. He requests an intervention to prevent
the progression to cancer. He states that he has not experienced heartburn, acid
regurgitation, dysphagia, and unintentional weight loss. You recommend:
a. PPI therapy for 6 months before repeat endoscopy b. Surveillance endoscopy in 6
months c. Photodynamic therapy d. Fundoplication e. Esophagectomy

‫الن‬Dysplasia is a histologic proxy for

genetic instability. It is difficult to distinguish dysplasia
from reactive atypia that is present in response to inflammation. The 2008 American College
of Gastroenterology guidelines recommend, even in the absence of erosive esophagitis, that
patients with newly diagnosed low-grade dysplasia alter the PPI regimen and undergo repeat
endoscopy in 6 months. If a patient is not already taking a PPI, he or she should begin taking
one, even if asymptomatic. If the patient is already using a PPI, confirm that he or she is taking
it correctly (meaning on an empty stomach, 20-60 minutes before chewing a solid). If the
medicine is taken correctly once daily, the patient has a choice of either increasing the dose to
twice daily or changing to a different PPI. Repeat endoscopy in 8 to 12 weeks serves two
purposes: to ensure healing of the esophagitis and to clarify the degree of dysplasia in the
underlying Barrett’s segment.

##A 75-year-old male swimmer with a 10-cm segment of Barrett’s esophagus is found at
surveillance endoscopy to have a 3-cm area of nodularity at the proximal aspect of the
Barrett’s segment. Six biopsy specimens from the nodular region show high-grade dysplasia, as
confirmed by two gastrointestinal pathologists. Biopsy specimens from the remaining Barrett’s
segment show high-grade dysplasia at the most distal aspect. Otherwise, biopsy specimens
show diffuse low-grade dysplasia. He has been taking a PPI for 7 years and is symptomatically
well. Chest and abdominal CT scans are without lymphadenopathy. There are no suspicious
lesions in the lungs or liver. The results of cardiac stress testing are normal. Both of the
patient’s parents lived well into their 90s, and he has always planned to do the same. For
treatment, you recommend:
a. Alteration of the PPI regimen, followed by repeat EGD in 3 months, with four-quadrant
biopsy specimens collected every 1 cm b. Endoscopic mucosal resection c. Endoscopic mucosal
resection, followed by photodynamic therapy d. Photodynamic therapy e. Esophagectomy

‫الن‬ Esophagectomy is the standard of care for patients confirmed to have high-grade
dysplasia. The 3-cm area of nodularity is of concern for concomitant neoplasm. Alteration of
the PPI regimen, followed by repeat EGD in 3 months with intensive biopsy sampling is an
option permitted by the American College of Gastroenterology. The underlying assumption of
this option is that definitive treatment will be recommended when the cancer is
demonstrated. The challenge is that locoregional micrometastases or, worse, distant
metastases may be present by that time. For patients with significant comorbid conditions
that also threaten longevity, this watchful waiting approach is very reasonable. Because the
patient is in otherwise excellent health, observation is a less attractive option. Performing
endoscopic mucosal resection for staging purposes is an excellent option, but it is not an
excellent choice for treatment in this scenario. Endoscopic mucosal resection is technically
easier to perform on lesions 1 cm or smaller in diameter .

11- Old Pnt with HX OF 20 Years GERD .he has nodule (Image of barret with dysplasia)The
best next step for histopathological invest.is:‫محمد عزيز‬/‫د‬
• EMR
• Esophagectomy
• EUS
• Radiation
# Best of five 4#A 70-year-old woman with a WHO performance status of 3 and COPD was
found to have a 2 x 6 cm flat adenocarcinoma of the oesophagus at 35 cm on OGD, not
bordering the gastro-oesophageal junction.
Investigations: endoscopic ultrasound:no evidence of lymphadenopathy
CT abdomen and pelvis: no evidence of lymphadenopathy, no distant metastases
Which is the next best option in her management?
A. Chemoradiotherapy
B. Endoscopic mucosal resection(EMR)
C. Endoscopic submucosal dissection
D. Radiofrequency ablation
E. Surgery with pre-operative chemotherapy
#Which of the following measures will result in reliable decrease in risk for esophageal adeno-
carcinoma in a patient with high grade dysplasia within short segment Barrett’s esophagus
A. Nissen fundoplication
B. Roux-en-Y gastric bypass
C. Esomeprazole double dose bid
D. Radiofrequency ablation
E. Celecoxib bid
#Surveillance in non-dysplastic Barrett’s##>>3-year(1 Year) + PPI
# Patient with Hx of GERD came for follow up, C2M5 non nodular with Prague classification of
Barrets esophagus, low grade dysplasia, what to do next?
>>No further treatment and follow up after 1 year
# A 54-year-old man with a long history of heartburn has an endoscopy to investigate his
symptoms. A biopsy is taken from an abnormal area of mucosa in the lower oesophagus and
reported as follows: Non-dysplastic columnar-lined oesophagus : What is the most suitable
management? -Reassure and discharge -Fundoplication -Laser ablation -Ivor-Lewis
oesophagectomy --High-dose proton pump inhibitor and follow-up> after 3 year
# Regurgitation, redness in the skin, arthritis, endoscopic finding#>Scleroderma
#Esophageal mass reaching adventitia, what is the stage?# ‫محمد عزيز‬/‫د‬T3
#Lower Esophageal mass reaching adventitia.the best investing. > Chest CT
#Malignant transformation of Barret’s esophagus in: ‫محمد عزيز‬/‫محمد جمال د‬/‫د‬
• 0.5 -1%( As mortality rate of pneumatic dilatation)
#Lower esophageal mass reaching adventitia, what is the best investigation?

• CT chest Thoracoscopy

#Tear in the esophagus is

• Anterolateral Posterolateral
• Lower third Fundus
NB: The majority of esophageal cancers are in the middle third of esophagus

#Old patient presented with dysphagia to solids, his EUS revealed small mass 2 X2 cm, what
is the next step?

• CT abdomen EUS PET scan

# EUS should be avoided in the diagnosis and staging of :

• Esophageal cancer after chemotherapy

• Stomach cancer

• Pancreatic cancer

• Small boewel enteropathy

NB: EUS used in the diagnosis and staging of :Esophageal cancer

,Stomach cancer,Pancreatic cancer ,Small boewel enteropathy (‫)سؤال اخر‬
#Best of five 4# A 28-year-old Brazilian man who complained of chest pain
was referred to the gastroenterology clinic by cardiology. He had a 1-year
history of episodic dysphagia and occasional regurgitation; his GP had
adequately trialled PPI and prokinetics. You organized gastroscopy,
oesophageal manometry, and pH studies, the results of which have been
reported as being consistent with achalasia. Protozoal serology is negative.
In this scenario, which of the following is the most appropriate first-line
management step?
A. Benznidazole
B. Botulinum toxin injection of the lower oesophageal sphincter
C. Surgery
D. Trial of calcium-channel blockers
E. Weight loss
#High resolution manometry(HRM) study#>>• DES ‫ رانيا‬/‫د‬

#High resolution manometry(HRM) study#>>• Achalasia ‫ رانيا‬/‫د‬

# Pathophysiology of achalasia > Degeneration of ganglion cells in myenteric
Aurbaches plexus of esophagus

# Acase c/o dysphagia to solid and liquid (i.e achalasia) investingation >
Barium swallowing

# 6. A 62-year-old woman with intermittent chest pains and dysphagia

comes to your office with a report from an outside institution, following an
esophageal motility test. The test report is as follows: “The lower esophageal
sphincter pressure was elevated at 52 mm Hg (normal 10-45) and, after wet
swallows, there was a failure of complete relaxation to the gastric baseline.”
Five of the 10 wet swallows were peristaltic and five wet swallows were
simultaneous. What is the most likely diagnosis?
a. Scleroderma
b. Achalasia
c. Diffuse esophageal spasm
d. Nutcracker esophagus
e. Nonspecific motility disorder

The definition of achalasia requires aperistalsis throughout the smooth

muscle part of the esophagus, often with increased LES pressure. A patient
with scleroderma would present with very low- amplitude esophageal waves
and occasionally with aperistalsis, although the LES tone would be very low.

Nutcracker esophagus is a phenomenon that has been described as high-

amplitude waves that are peristaltic. According to the definition of diffuse
spasm, more than 30% of the wet swallows are simultaneous but occasional
peristalsis is present.

12. A 48-year-old man presents with a 4-year history of dysphagia. His

symp- toms began insidiously but have now progressed to the point that he
has trouble swallowing at every meal and has difficulty with liquids as well as
solids. He has a sense that food sits in his chest. If he interrupts his meal and
waits, the food often passes down into his stomach, particularly after he
drinks a large amount of water. However, he has been noticing some
nasopharyngeal regurgitation when attempting this maneuver and also
notices regurgitation of sour fluid when he bends over. His weight had been
stable, but with progressive symptoms over the past 12 months or so, he has
now lost approximately 10 lb. Findings on upper endoscopy were unre-
markable, including a retroflexed view of the gastroesophageal junction. A
manometric recording from the patient is shown below.
What is the diagnosis?

a. Achalasia
b. Nutcracker esophagus

c. Esophageal spasm
d. Severe GERD
e. Scleroderma

Manometry shows aperistalsis in the body of the esophagus, increased

resting LES pressures, and incomplete relaxation of the LES. This history and
these manometric findings are classic for achalasia.
## 14. A 48-year-old woman presents with a 2-year history of progressive
dysphagia. During a recent episode, food got caught in her chest for an hour.
She decided to go to the emergency department, but en route, the dysphagia
spon taneously resolved and she returned home. She also has a history of
progressively severe heart- burn over the past 4 to 5 years. Initially, she had a
response to once-daily PPI, but therapy became refractory to the treatment.
More recently, she has been taking antacids in addition to the PPI, but this
affords only partial relief. She has lost approximately 10 lb over the past 6
months because of progressive dysphagia. She states that she does not have
any fever, chills, or sweats but has noticed that her fingers often become
white or even purple and painful when she is in the cold. EGD shows severe
distal esophagitis with a stricture, but no evidence of a mass or Barrett’s
esophagus. What is the diagnosis?
a. Severe GERD b. Pill esophagitis
c. Scleroderma d. Eosinophilic esophagitis
#Regarding scleroderma. All are manifestation of scleroderma exept >
can cause hypertrophy
#MRCP Q BANK #A 54-year-old female presents with a 3 month history of
dysphagia affecting both food and liquids from the start, along with
occasional symptoms of heartburn. What is the most likely underlying
diagnosis? -Pharyngeal pouch -Gastric adenocarcinoma -Benign stricture -
Oesophageal cancer -Achalasia

#MRCP Q BANK#A 71-year-old man presents with two year history of

intermittent problems with swallowing. His wife has also noticed he has
halitosis and is coughing at night. He has a past medical history of type 2
diabetes mellitus but states he is otherwise well. Of note his weight is stable
and he has a good appetite. Clinical examination is unremarkable. What is
the most likely diagnosis? Oesophageal cancer Hiatus hernia
Pharyngeal pouch Oesophageal candidiasis Benign oesophageal stricture
## A 42-year-old man with a 7-year history of regurgitation and
heartburn has come to you because of worsening symptoms. He
describes difficulty getting food down (both liquids and solids). Also,
when he bends down, he occasionally regurgitates all food. He has
had to elevate the head of his bed. A barium swallow study was
performed. The most likely diagnosis is:a. Scleroderma b. Achalasia
c. Diffuse esophageal spasm d. Nutcracker esophagus
‫ الن‬The radiograph clearly shows findings typical of achalasia, that is, a
dilated esophagus that tapers, producing a “bird’s beak”
appearance. With diffuse spasm, the radiograph would show a more
corkscrew appearance. With scleroderma, the radiograph may be
normal, with a widely patent LES. Nutcracker esophagus is a
manometric finding, with the mean distal esophageal amplitude
more than 180 mm Hg. Peristalsis is maintained and, in most cases,
the esophagogram is normal.
##young age with dysphagia (Barium swallowing picture>Bird or
Barrots beak appearance at the distal esophagus)D is >> Achalasia

## A 62-year-old woman with intermittent chest pains and dysphagia

comes to your office with a report from an outside institution,
following an esophageal motility test. The test report is as follows:
“The lower esophageal sphincter pressure was elevated at 52 mm Hg
(normal 10-45) and, after wet swallows, there was a failure of
complete relaxation to the gastric baseline.” Five of the 10 wet
swallows were peristaltic and five wet swallows were simultaneous.
What is the most likely diagnosis?
a. Scleroderma b. Achalasia c. Diffuse esophageal spasm
d. Nutcracker esophagus e. Nonspecific motility disorder
‫الن‬The definition of achalasia requires aperistalsis throughout the
smooth muscle part of the esophagus,often with increased LES
pressure. A patient with scleroderma would present with very low
amplitude esophageal waves and occasionally with aperistalsis,
although the LES tone would be very low. Nutcracker esophagus is a
phenomenon that has been described as high-amplitude waves that
are peristaltic. According to the definition of diffuse spasm, more
than 30% of the wet swallows are simultaneous but occasional
peristalsis is present.
‫الخالصه‬
@Esophageal body problem:
A)spasm with peristalsis= DES
B)Jachammer esophagus>normal peristalsis but powerful ‫قويه زي الشاكوش‬
C )Nutcracker esophagus> As Jackhammer but from 5 – 8
@ LES :
A)Achalesia>high LES pressure ‫عال علطول عندها فديما قافل‬
‫ الضغط ي‬cardia
No peristalsis in the esophageal body ‫ش ممي وهو‬ ‫وبيكون معاها ئ‬

B)Pseudoacalasia>Old age with non fungating mass(Biopsy ‫) وهنا الزم ناخد‬

peristalsis in the esophageal body ‫وبيكون معاها‬
# 11- Cancer esophagus extending to adventitia, what is TNM classification?
• T3N0M
12- #DHA#20 year old c/o dysphagia. Image of impedence test. The proper
treatment is :

• Lap. Heller myotomy(achalasia ‫)الن دي حاله‬

• Open Heller myotomy
• CCB
• Butulinium toxin injection
(if old age > butulinium injection) and (if medical ttt > Nifedipine)

13- Barium image, what is the diagnosis?#

• Achalasia ( Bird or parrot beak appearance)

14- Male patient, presented with dysphagia, aspiration most of the time,
regurgitation of food, no weight loss

• Achalasia
• Meckel’s diverticulum
• Pharyngeal pouch
• Esophageal cancer
• Esophagectomy
‫مايو‬##Mortality rate from pneumatic dilation of the esophagus

• 0.5-1.5% ( As % of incidence of adenocarcinoma in Barrets esoph.q7)

#Alcoholic patient developed upper GI bleeding, what is the most

common cause?#
 • Esophageal varices
• Peptic ulcer
• Coagulopathy
• Cancer stomach
• #What is the most important risk factor of esophageal
adenocarcinoma?#
• Obesity
• Excess alcohol
• Smoking
#Best of five 3#A 72-year-old man presented with a 3-week history of
dysphagia and was found to have a large oesophageal adenocarcinoma at 37
cm.
Which of the following is the most significant predisposing factor in the
pathogenesis of oesophageal adenocarcinoma?
A. Alcohol excess
B. Helicobacter pylori infection
C. Obesity
D. Smoking
E. Social deprivation

#25 year old male presented with dysphagia, regurgitation, heartburn,

barium swallow revealed Barrot peak appearance#

• Achalasia
#HIV patient presented with dysphagia, EGD revealed ulcers of the
esophagus, biopsies revealed infected epithelial cells with intranuclear
inclusions, what is the pathology?

• Candidiasis
• HSV esophagitis
• CMV esophagitis

15- Picture of achalasia by barium swallow, what is the best treatment?

• Laparoscopic Heller myotomy

• Open myotomy
• Premature endoscopic dilation

16- Yung age with dysphagia (Image of achalasia>>Bird appearance)

17- Achalasia best surgery

• Open Heller myotomy

• Lap. Heller myotomy
• Nissen fundoplication

#Pathophysiology of achalasia

• Loss of Auerbach’s plexus

• Hypertrophy of LES
•

#A case of persistent symptoms of GERD in spite of maximum dose of

PPI is for>>pH manometry
#22 year old patient presented with achalasia, what is the treatment?

• Esophagectomy(Heller myotomy)
• Pneumatic dilation
• PPI

#Patient with dysphagia, what’s the cause (with Barium image> Bird or
barrot peake apperance)

• Achalasia
• DES
• Functional
• Obstruction
 #50 year old patient with progressive painless dysphagia of 1 month, no
fever or cough, ulcer was found 24 cm from incisura (with image)

• Adenocarcinoma
• Squamous cell carcinoma( ‫لو السيناريو‬GERD>Esoph. adenocarcinoma)

#22 year old male patient presented with progressive dysphagia first to
solids, then to liquids. EGD is normal, what is the treatment?

• Ca Channel blocker
• Avoid cold food
• Myotomy
• PPI

#What is the medical treatment for dysphagia of achalasia?

• Amlodipine
• Nifedipine
• Isosorbide nitrate
#Best of five 3# A 37-year-old Brazilian man who complained of chest pain
was referred to the gastroenterology clinic by cardiology. He had a history of
episodic dysphagia and occasional regurgitation; his GP had adequately
trialled PPI and prokinetics.
WS

7:40.6 15 sec 9:10.4

Investigations:Gastroscopy: normal
oesophageal pH studies: DeMeester score 11
oesophageal motility studies:simultaneous high-amplitude contractions with
40% of swallows, but intermittently normal peristaltic waves and a high
resting pressure at the lower oesophageal sphincter (LOS). There is normal
relaxation during swallowing. What is the most likely diagnosis?
A. Achalasia
B. Chagas disease
C. Diffuse oesophageal spasm
D. Gastro-oesophageal reflux disease
E. Nutcracker oesophagus

#Male patient presented with chest pain, dysphagia, chest pain increases
during night, esophageal study(HRM) shows non effective swallowing in >
20% of swallows, what is the diagnosis?# ‫بدون صورة‬HRM

• DES(Diffuse esophageal spasm)

• Achalasia
• Nutcracker esophagus
##DES >> Normal LES relaxation/LES is normal or high or low/loss of
sequential esophageal peristalsis with simultaneous higj-amplitude
contraction in more than >10%( in exam it was 20% plus high CFV i.e
contractile force velocity )
#Old patient presented with dysphagia, weight loss, UE was done
revealing deep ulcer at 25 cm from incisura, what is the diagnosis?

• Squamous cell carcinoma

• Adenocarcinoma

18- Patient with achalasia presented with dysphagia to liquids, what is

the best initial medical treatment?

• Isosorbide dinitrate
• Nifedipine???????
• Amlodipine

19- Patient presented with progressive dysphagia to solids , regurgitation

(image of barium swallow), what is the diagnosis?

• Achalasia

#Child 7 year old, drank house cleaner 2 hours ago, presented with
chest pain, examination revealed oral and mouth ulcers and erosions
(painful), what is better for evaluation of esophagus?#

• CT abdomen
• Plain X-ray
 • Upper GI endoscopy
• Barium swallow

#Cirrhotic patient, decompensated, alcoholic cirrhosis, he was

presented with hematemesis and stabilization occurred. Endoscopy
revealed small OVs but with oozing blood. What is not recommended?

• Antibiotics

• Sandostatin

• EVL

• Factor VII (activated)

#Treatment of esophageal varices> Band ligation(EVL)

# Regarding to TLESR which is true#‫ محمد السيد‬/‫د‬

• They are associated with esophageal peristalsis

• They occur independent of swallowing

• They persist longer than 10 sec then swallow induced

• Accompanied by inhibition of crural diaphragm

• Account for nearly all episodes of GERD

# 35 years old Patient with known history of (allergic rhinitis)bronchial
asthma, diagnosed with eosinophillic esophagitis, received treatment by PPI
for 3 months with no improvement(EGD Image of esinophilic esophagitis),
what is the best treatment? #‫محمد السيد‬/‫لمياء د‬/‫د‬
• Oral fluticasone
• Oral Budesonide
• Dilatation
• Change type of PPI
‫بيج سؤال بس بصيغه تانيه بيقول‬
‫ي‬ #
#Acase of esinophilic esophagitis established diagnosed . the first line of ttt is
>> Proton pump inhibitors (PPI)
# Female Pnt c/o chest pain at night and improved not related to
food.relaxation presuure 8 (i.e normal= not achalasia ), abnormal contraction
>20% of swallowin( No image in this quation) ‫لمياء‬/‫ محمد عزيزد‬/‫د‬Diagnosis is : DES
#Barret with low grade dysplasia>surveillance after1 year (6)+PPI) #‫محمد السيد‬/‫د‬
# Barret with high grade dysplasia> RFA /ESOPHAGECTOMY) . #‫محمد السيد‬/‫د‬
#Patient was presented with dysphagia and large esophageal
carcinoma was discovered .Esophageal cancer palliation for tumor reatch
trachea. what’s the best treatment:# ‫محمد عزيز‬/‫محمد السيد د‬/‫د‬
• Self expanding stents • Plastic stents
• Metal stents • Esophagectomy
#46 year old female presented with raynaud’s , dysphagia, manometric
pattern of Sclerodema. Diagnosis is: scleroderma
#45 Years old Pnt c/o regurgitation,dysphagia, chest pain, reflux, redness of
skin and arthritis i.e Raynaudes phenomenon.(EGD image and HRM)
Diagnosis is:‫ محمد السيد‬/‫د‬
-Scleroderma -DES -achalasis -Nutcraker esophagus
#DHA#Best investigation in new onset dysphagia#‫محمد السيد‬/‫د‬
• Upper endoscopy• X-ray/Manometry
• Barium swallow• EUS
# years child swallowed corrosive material(home cleaner) 12 hours he is
hemodynamically stable after resuscitation, presented only with painful
ulceration,chest pain. The first investigation is>upper enoscope ‫محمد السيد‬/‫د‬
‫محمد عزيز‬/‫د‬
#Immage of EGD >> Barret esophagus ‫ لمياء‬/‫د‬
# Which of the following is risk factor for esophageal adenocarcinoma
‫محمد السيد‬/‫محمد عزيز د‬/‫ • د‬Smoking• Alcohol• Obesity
#Male patient, 32 year old presented with dysphagia, his barium study
revealed achalasia, what is the appropriate treatment?#‫محمد السيد‬/‫د‬
• Ca channel blocker • Local botulinum toxin injection(if old patient)
• Refer for surgery( ‫محمد السيد‬/‫د‬if young patient) • PPI
# Gold standered investigation of GERD IS >> Ambulatory pH monitoring
 #Best of five 2#A 46-year-old man was reviewed in clinic with
troublesome symptoms of reflux occurring at any time of day, for the
last 2 years. He hada gastroscopy six months ago which was normal.
He had taken omeprazole 40 mg BD and metoclopramide 10 mg TDS
for eight months. He had previously tried an H2-receptor antagonist in
addition to this, with no benefit. He had no lifestyle risk factors for

reflux.What is the next most appropriate management step?

‫محمد السيد‬/‫سناء د‬/‫د‬
A. Ambulatory oesophageal pH and manometry studies
B. Barium swallow
C. Fasting gastrin level
D. Peripheral blood eosinophil count
E. Repeat endoscopy
‫ اسئله‬3 ‫جه فيها‬Achalesia(HRM/Barium image/ttt) ‫ محمد السيد‬/‫د‬

HRM ‫ اسئله‬3 ‫>> جه فيه‬Achalesia/ DES/Nutcracker ‫تقريبا‬

‫سؤال عن ال‬PH in first day…. 2nd day….. 3rd day…..>>??Nifidipine

#A 58-year-old woman under surveillance for Barrett’s oesophagus was
found to have high-grade dysplasia in four biopsies at gastroscopy. Repeat
gastroscopy and further biopsies confirmed this. The Barrett’s segment
appeared uncomplicated macroscopically, and was circumferential and 5 cm
in length (Prague C5M5). She was taking a high-dose proton pump inhibitor.
She declined surgical intervention. ‫لمياء‬/‫د‬
Which of the following is the most appropriate management step?
A. Argon plasma coagulation B. Endoscopic mucosal resection
C. Laser ablation D. Multipolar electrocoagulation
E. Radio-frequency ablation(RFA)
 #A patient presented with cough, fever with esophageal ulcer with
elevated edge (with image):#‫محمد السيد‬/‫د‬
• TB (Esophageal Tuberculosis) • Adenocarcinoma
• Barrett’s esophagus
12- Adenocarcinoma invading adventitia, which stage?# ‫محمد السيد‬/‫د‬
• T0 T1 T2 T3
#Pathophsyology of zenker diverticulum> Herniation of the mucosa and
submucsa of the hypopharynx through weak area of the posterior
hypopharyngeal wall ‫امية‬/‫ لمياء د‬/‫د‬
#Pnt with epigastric pain and cough. Diagnosis is>GERD
(EXTRA ESOPHAGEAL SYMPTOM)‫د لمياء‬
#A 64-year-old female with a history of COPD and hypertension presents with
pain on swallowing. Current medication includes a salbutamol and becotide
inhaler, bendrofluazide and amlodipine. What is the most likely cause of the
presentation? -------Myasthenia gravis precipitated by bendrofluazide -
Oesophageal web -Achalasia secondary to amlodipine
-Oesophageal candidiasis -Oesophageal cancer
# Old female patient presented with dysphagia to solids(ODYNOPHAGIA), her
EGD revealed white plaques in the lower esophagus, what is the diagnosis
(with image)?
- Candidiasis -Barrett’s esophagus -HIV - Esophagitis
The same scenario and asking about the ttt > Nystatin ‫لمياء‬/‫د‬

NB:Pain on swallowing (odynophagia) is a typical of oesophageal candidiasis,

a well documented complication of inhaled steroid therapy .

#High resolution manometry(HRM) study#>>• DES ‫ رانيا‬/‫د‬

#High resolution manometry(HRM) study#>>• Achalasia ‫ رانيا‬/‫د‬