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CHAPTER 2 | OESOPHAGEALDISORDERS
3. A 70- year- old woman with a WHO performance status of 2 and mild
inhaler controlled chronic obstructive pulmonary disease (COPD) was
found on gastroscopy to have a 45mm at adenocarcinoma of the
oesophagus at 35cm, not bordering the gastro- oesophageal junction.
Investigations:
Endoscopic ultrasound Tumour invades lamina propria but not submucosa, no
regional lymphadenopathy
PET- CT chest, abdomen,
No evidence of lymphadenopathy, no distant metastases
pelvis
Which is the next best option in her management?
A. Chemoradiotherapy
B. Endoscopic mucosal resection (EMR)
C. Palliative care
D. Radiofrequency ablation
E. Surgical resection
4. A 76- year- old man was diagnosed with metastatic oesophageal
adenocarcinoma. Aself- expanding metal stent (SEMS) was inserted to
relieve his dysphagia but he requested this to be removed because of
persistent chest discomfort in the absence of oesophageal perforation.
His WHO performance status was 3.
Which of the following is a useful option in the palliation of dysphagia for
this patient?
A. Botulinum toxin injection
B. Brachytherapy
C. Calcium channel blockers
D. Chemotherapy
E. Local ethanol injection
5. An 83- year- old man with T4N1M1 oesophageal adenocarcinoma was
admitted with progressive dysphagia. He requested to be managed
symptomatically and a SEMS had been suggested.
Which of the following statements is true regarding SEMS in malignant
oesophageal strictures?
A. Brachytherapy should not be used at the same time as SEMS placement
B. Photodynamic therapy is superior to SEMS in the palliation of malignant dysphagia
C. SEMS is contraindicated in the presence of a tracheo- oesophageal stula
D. SEMS should be inserted in advance of palliative radiotherapy for dysphagia
E. SEMS should not be used as a bridge to denitive surgery
CHAPTER 2 | QUESTIONS
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6. A 47- year- old man attended for a gastroscopy to investigate persistent
hoarseness of voice, cough, and sore throat. He had previously seen the
ear, nose, and throat team who had performed exible nasendoscopy
and commented that the laryngeal folds were mildly erythematous.
They wondered whether his symptoms were caused by acid reux.
Investigations:
Gastroscopy A salmon- coloured area was seen at 18cm from the incisors
(Fig. 2.1). Otherwise this was a normal endoscopy.
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Fig.2.1 Endoscopic image of upper oesophagus. See also Plate 2
Image courtesy of Oxford University Hospitals NHS Foundation Trust
What is the diagnosis?
A. Barrett’s oesophagus
B. Candidiasis
C. Cervical inlet patch
D. Squamous cell carcinoma
E. Tracheo- oesophageal stula
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CHAPTER 2 | OESOPHAGEALDISORDERS
7. A 46- year- old man was reviewed in clinic with a two- year history
of heartburn and regurgitation. His symptoms persisted despite
omeprazole 40 mg twice daily.
Investigations:
Gastroscopy No evidence of erosive oesophagitis
Oesophageal
Four eosinophils per high- power eld
histology
What is the next most appropriate step?
A. Barium swallow
B. Fasting gastrin level
C. Long- term metoclopramide
D. Oesophageal pH/ impedence studies
E. Trial of swallowed budesonide
8. A 53- year- old man was reviewed for persistent heartburn and nocturnal
cough despite omeprazole 40 mg twice daily and lifestyle optimization.
Agastroscopy two years previously had demonstrated LA Grade C
oesophagitis, and recent pH/ impedence monitoring conrmed ongoing
pathological acid reux. Manometry was normal. He was keen to
explore surgical options to manage his condition.
Which of the following statements about anti- reux surgery is most
accurate?
A. Laparoscopic fundoplication is less eective than open fundoplication at relieving heartburn
and regurgitation but has lower mortality
B. Laparoscopic magnetic sphincter augmentation results in lower rates of gas bloating than
laparoscopic Nissen fundoplication
C. Most patients with post- operative dysphagia will require revisional surgery
D. Nissen fundoplication is preferred over Toupet fundoplication for patients with
oesophageal motility disorders
E. Transoral incisionless fundoplication is the operation of choice for most patients
9. A 71- year- old woman was reviewed in clinic following a surveillance
endoscopy for Barrett’s oesophagus.
Which of the following histopathological features best supports a
diagnosis of Barrett’s oesophagus without dysplasia?
A. Cardiac- type columnar cells bordering squamous mucosa
B. Columnar mucosa with nuclear pleomorphism in all cells seen
C. Gastric- type mucosa with a similarity in nuclear/ cytological appearances between the crypt
base cells and those at the surface epithelium
D. Increased foci of mitotic activity seen at the gastro- oesophageal junction
E. Intestinal metaplastic glandular mucosa with adjacent oesophageal ducts
CHAPTER 2 | QUESTIONS
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10. A 63- year- old man attended for surveillance gastroscopy for Barrett’s
oesophagus.
Investigations:
Gastroscopy C3M6 Barrett’s oesophagus with no visible lesions
Histology Consistent with Barrett’s oesophagus with evidence of low-
grade dysplasia in two biopsies (conrmed by a second expert
gastrointestinal pathologist)
How should he be managed?
A. Endoscopic resection of Barrett’s oesophagus
B. Laparoscopic oesophagectomy
C. Radiofrequency ablation
D. Repeat endoscopy in six months
E. Repeat endoscopy in 2months
11. A 53- year- old man attended for a gastroscopy to investigate persistent
reux symptoms.
Investigations:
Gastroscopy C5M7 Barrett’s oesophagus
Histology Consistent with Barrett’s oesophagus with intestinal metaplasia
(IM) but no evidence of dysplasia
The patient is keen for surveillance because he is concerned about the
risk of oesophageal cancer. When should he receive his next endoscopy?
A. Between two and three years
B. Between three and ve years
C. Between eight and ten years
D. No surveillance
E. Within six months to conrm the diagnosis
12. A 67- year- old woman with Barrett’s oesophagus was found to have an
area of high grade dysplasia at recent surveillance endoscopy.
Regarding visible foci of high- grade dysplasia in Barrett’s oesophagus,
which of the following statements are true?
A. Fewer than 5% of patients with a visible dysplastic focus will develop metachronous lesions
over the subsequent two years
B. Once the focus of high- grade dysplasia has been resected, the patient should receive
surveillance endoscopy after two years
C. PET- CT should be performed prior to endoscopic resection of high- grade dysplasia
D. The ‘cap and snare’ technique is more eective at resecting visible lesions than band ligation
E. When endoscopic resection is performed, histological examination of the resection specimen
is the most accurate staging technique for Barrett’s oesophagus- related early neoplasia
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CHAPTER 2 | OESOPHAGEALDISORDERS
13. A 75- year- old man presented with a six- month history of non- cardiac
chest pain and intermittent dysphagia to solids and liquids.
Investigations:
Gastroscopy Grade Areux oesophagitis
Oesophageal
Average distal peristaltic amplitude >180mmHg
manometry
What is the diagnosis?
A. Achalasia
B. Diuse oesophageal spasm
C. Hypertensive lower oesophageal sphincter
D. Ineective oesophageal motility
E. Nutcracker oesophagus
14. A 37- year- old Brazilian man with a history of non- cardiac chest pain was
referred to the gastroenterology clinic by cardiology. He described a
history of episodic dysphagia and occasional regurgitation that persisted
despite PPI therapy and a short trial of prokinetics.
Investigations:
Gastroscopy Normal
Oesophageal pHstudies DeMeester score 11.3
Oesophageal motility
studies
What is the most likely diagnosis?
A. Achalasia
B. Chagas disease
C. Distal (diuse) oesophageal spasm
D. GORD
E. Jackhammer oesophagus
Premature contractions in 35% of swallows; normal relaxation
of the gastro- oesophageal junction during swallowing. The
distal contractile integral never exceeds 8,000mmHg/ cm/ s.
CHAPTER 2 | QUESTIONS
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15. A 44- year- old patient presented with a two- year history of progressive
dysphagia and occasional retrosternal discomfort. Dysphagia occurred
for both solids and liquids. Following a normal upper gastrointestinal
endoscopy, the patient underwent high- resolution oesophageal
manometry.
Investigations:
High resolution oesophageal manometry (Fig. 2.2)
Integrated relaxation pressure (IRP) 28mmHg (normal <15)
Distal contractile integral (DCI) 90 (normal 450– 8,000)
Distal latency (DL)— not calculated as DCI <450
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Fig.2.2 Pressure topography plot obtained during high resolution oesophageal manometry. See
also Plate 3
Image courtesy of Dr Tanya Miller, Principal Clinical Scientist in GI Physiology, Oxford University Hospitals NHS Foundation Trust
What is the most likely diagnosis?
A. Absent contractility
B. Pseudoachalasia
C. Type Iachalasia
D. Type II achalasia
E. Type III achalasia
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CHAPTER 2 | OESOPHAGEALDISORDERS
16. A 64- year- old Argentinian man presented to the gastroenterology clinic
complaining of dysphagia and regurgitation of undigested food. Systemic
examination revealed an irregular pulse and pitting oedema of the
lower limbs.
Investigations:
Gastroscopy Grossly dilated oesophagus containing undigested food and
uid. The lower oesophageal sphincter was slow to relax
with otherwise normal appearances to the oesophago- gastric
Which of the following investigations would conrm the diagnosis?
A. CT thorax
B. High- resolution oesophageal manometry
C. Thick and thin lm microscopy with Giemsa stain
D. Treponema whipplei serology
E. Trypanosoma cruzi serology
junction.
CHAPTER 2 | QUESTIONS
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17. An 87- year- old man presented with weight loss, one year of worsening
dysphagia and regurgitation of both solids and liquids. Past medical
history included ischaemic heart disease, hypertension, chronic kidney
disease, and recurrent falls.
Investigations:
Gastroscopy Dilated oesophagus with some food residue, normal stomach
and duodenum
CT chest, abdomen
and pelvis
No extrinisic compression of the gastro- oesophageal junction
(Fig. 2.3)
25
Fig.2.3 CT chest and upper abdomen.
Image courtesy of Dr Emma Culver, Consultant Gastroenterologist, Oxford University Hospitals NHS Foundation Trust
What is the next best treatment approach?
A. Botulinum toxin injection to the lower oesophageal sphincter
B. Laparoscopic Heller myotomy (LHM)
C. Oesophagectomy
D. Peroral endoscopic myotomy
E. Short- acting calcium antagonist
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CHAPTER 2 | OESOPHAGEALDISORDERS
18. A 21- year- old woman with asthma underwent an endoscopy to
investigate dysphagia.
Which statement regarding eosinophilic oesophagitis is correct?
A. An empiric six- food elimination diet achieves histologic remission in 0% of patients
B. Diagnosis requires a two- month trial of a proton pump inhibitor (PPI) with persistence of
eosinophilia on oesophageal biopsy
C. Endoscopic dilation is a safe procedure, with a risk of oesophageal perforation <%
D. Male gender is a protective factor
E. Prevalence has decreased in the past 0years
19. A 19- year- old woman was admitted from a local psychiatric hospital
four- hours after ingesting a cylindrical battery, a scalpel blade, and
three coins. Chest and abdominal radiography suggested the items
were in the stomach. She was able to swallow without diculty and was
clinically well.
Which of the following management strategies is most appropriate?
A. Endoscopy within six hours with an overtube
B. Endoscopy within six hours without an overtube
C. Endoscopy within 24 hours with an overtube
D. Endoscopy within 24 hours without an overtube
E. Urgent laparotomy
20. A 19- year- old woman presented to the emergency department three
hours after ingesting approximately 300 ml of car battery uid following
an argument with her partner. Her abdomen was tender but not
peritonitic and there was no palpable surgical emphysema. There were
no signs of airway compromise.
Which of the following should form part of initial management?
A. Broad spectrum antibiotics and corticosteroids
B. Endoscopy between 2 and 24 hours of ingestion
C. Intubation and ventilation
D. Oral ammonia as a neutralizing agent
E. Oral hypertonic saline to induce vomiting
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chapter
OESOPHAGEAL DISORDERS
2
1. A. Alcohol
• Risk factors for squamous cell oesophageal cancer include smoking, alcohol, N- nitroso
compounds, and atrophic gastritis
• Alcohol excess is not a risk factor for oesophageal adenocarcinoma
Rates of oesophageal squamous cell carcinoma are highest in Northern Iran, Central Asia and
North Central China. Key risk factors include cigarette smoking and alcohol consumption (notably
there is no association between alcohol intake and oesophageal adenocarcinoma). Dietary factors
that have been implicated include those rich in N- nitroso compounds (e.g. pickled foods), areca
nuts, betel quid, and low selenium or zinc intake. Atrophic gastritis increases the risk of oesophageal
squamous cell carcinoma as does a previous partial gastrectomy. Human papillomavirus serotypes
6 and 8 may be associated, as may oral bisphosphonates.
GORD and obesity are risk factors for oesophageal adenocarcinoma. Non- steroidal antiinammatory drugs may be protective against oesophageal adenocarcinoma, and the impact of
H.pylori on oesophageal cancer risk is not yet fully understood.
Xie SH, Lagergren J.Risk factors for oesophageal cancer. Best Pract Res Clin Gastroenterol. 208;36–
37:3– 8. Doi:0.06/ j.bpg.208..008.
2. D. PET- CT, EUS, and tracheobronchoscopy
• PET- CT is recommended in all oesophageal carcinoma patients with potentially resectable disease
• EUS should be used to stage the T (tumour) and N (lymph node) categories in oesophageal
carcinoma
• Tumours located either within the proximal oesophagus, or at the oesophago- gastric junction,
may require additional staging investigations
European Society for Medical Oncology (ESMO) guidelines recommend PET- CT to exclude
distant metastases in all potentially resectable oesophageal cancers. EUS has a sensitivity of 8%–
92% and specicity of 94%– 97% when used for oesophageal tumour staging, and it is therefore
recommended for use in staging oesophageal tumours. In the case discussed here, the tumour is
located in the upper thoracic oesophagus at 22cm from the incisors. Because this is above the level
of the carina (25cm), ESMO guidelines additionally recommend tracheobronchoscopy to exclude
tracheal invasion. Staging laparoscopy would be an appropriate staging investigation for the locally
advanced (T3/ 4) oesophago- gastric junction tumours in which peritoneal metastases are detected
in approximately 5% of patients.
Lordick F, Mariette C, Haustermans K etal. Oesophageal cancer:ESMO Clinical Practice Guidelines
for diagnosis, treatment and follow- up. Ann Oncol. 206;27(suppl 5):v50– v57.
ANSWERS
Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor,
Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press.
DOI: 10.1093/oso/9780198834373.003.0002
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