trào ngược dà dày thực quản (GERD)

[1]  NERD non-erosive reflux disease: characteristic symptoms of gastroesophageal reflux disease in the absence of esophageal injury, such as reflux esophagitis, on endoscopy 50–70% of

Gastroesophageal reflux disease I/ Summary

Gastroesophageal reflux disease (GERD) is a chronic condition in which retrograde flow of stomach contents into the esophagus causes irritation to the epitheliallining Reflux episodes are primarily caused by inappropriate, transient relaxation of the lower esophageal sphincter (LES) Risk factors include smoking, alcohol consumption, stress, obesity, and anatomical abnormalities of the esophagogastric junction (e.g., hiatal hernia) The chief complaint is retrosternal burning pain(heartburn), but a variety of other symptoms, such

as dysphagia and a feeling of increased pressure, are also common Suspected GERD should already receive empirical treatment, but further diagnostic steps, such as an upper endoscopy and/or 24-hour pH test, may be indicated to confirm the diagnosis Management involves lifestyle modifications, medications, and possibly surgery Proton pump inhibitors (PPIs) are the treatment of choice, although other agents – such as histamine H2-receptor antagonists (H2RAs) – may also be helpful In addition to relieving symptoms,

treating esophagitis is especially important, as chronic mucosal damage can lead to a premalignant condition known as Barrett's

esophagus, further progressing to adenocarcinoma of the esophagus

II/ Definition

 Gastroesophageal reflux: regurgitation of stomach contents into the esophagus (can also occur in healthy individuals, e.g., after

consuming greasy foods or wine)

including heartburn or regurgitation) and/or esophageal injury/complications The most common endoscopic finding associated with esophageal mucosal injury is reflux esophagitis [1]

 NERD (non-erosive reflux disease): characteristic symptoms of gastroesophageal reflux disease in the absence of esophageal injury, such as reflux esophagitis, on endoscopy (50–70% of GERD patients) [2]

 ERD (erosive reflux disease): gastroesophageal reflux with evidence of esophageal injury, such as reflux esophagitis, on endoscopy (30–50% of GERD patients)

III/ Epidemiology

 Sex: ♀ = ♂ [3]

IV/ Etiology

 Main mechanism: transient lower esophageal sphincter relaxations (tLESRs) [5]

 The dysfunctional LES loosens independent of swallowing and has a decreased ability to constrict, which

allows stomach contents to uncontrollably flow back into the esophagus (otherwise known as sphincter insufficiency)

 Causes ∼⅔ of reflux episodes

 Risk factors/associations

 Lifestyle habits such as smoking, caffeine and alcohol consumption

 Stress

 Obesity

 Pregnancy

 Diaphragm dysfunction

 Angle of His enlargement (> 60°)

 Iatrogenic (e.g., after gastrectomy)

 Inadequate esophageal protective factors (i.e., saliva, peristalsis) [5]

 Gastrointestinal malformations and tumors: gastric outlet obstruction, gastric cardiac carcinoma

 Sliding hiatal hernia: ≥ 90% of patients with severe GERD

V/ Clinical features

 Chief complaint: retrosternal burning pain (heartburn) that worsens while lying down (e.g., at night) and after eating

 Pressure sensation in the chest

 Belching, regurgitation

 Dysphagia

 Chronic non-productive cough and nocturnal cough

 Nausea and vomiting

 Halitosis

 Triggers:

 Bending down, supine position

 Habits: smoking and/or alcohol consumption

 Psychological factors: especially stress

VI/ Diagnostics

from lifestyle modifications to a short trial with PPIs – should be initiated A GERD diagnosis is assumed in patients who respond to this therapeutic regimen

 Upper endoscopy (esophagogastroduodenoscopy (EGD))

 Used to classify reflux esophagitis and conduct biopsies

 Indications for endoscopy

 Signs of complicated disease (e.g., dysphagia, painful swallowing, weight loss, iron deficiency anemia, and aspiration pneumonia)

 Extended course of symptoms

 Noncardiac chest pain

 No response to PPI treatment

 Esophageal pH monitoring

 Measured over 24 hours via nasogastric tube with a pH probe

 Sudden drops to a pH ≤ 4 are consistent with episodes of acid reflux into the esophagus

 Indications

 To confirm suspected NERD

 Before endoscopic or surgical treatment options are initiated in patients with NERD

 GERD is diagnosed when drops in esophageal pH correlate with symptoms of acid reflux and precipitating activities noted in the patient's event diary

 Esophageal manometry

 A pressure-sensitive nasogastric tube measures the muscle contractions in several sections of the esophagus while the patient swallows

 Indications:

 Ensure correct placement of pH probes

 Evaluate peristaltic function prior to anti-reflux surgery

 Exclude motor disorders that may mimic the symptoms of GERD

VII/ Pathology

The histopathological findings vary depending on the severity of mucosal damage:

 Superficial coagulative necrosis in the non-keratinized squamous epithelium

 Thickening of the basal cell layer

 Elongation of the papillae in the lamina propria and dilation of the vascular channels at the tip of the papillae (→ hyperemia)

 Inflammatory cells (granulocytes, lymphocytes, macrophages)

 Transformation of squamous into columnar epithelium → Barrett's metaplasia

VIII/ Differential diagnoses

1 Other forms of esophagitis

 Infectious esophagitis: generally in immunocompromised patients

 Esophageal candidiasis: Endoscopy shows white or yellowish adherent plaques

 Herpes esophagitis: Endoscopy shows superficial ulcers in the upper or mid esophagus in the absence of plaques

 CMV esophagitis: Endoscopy shows distal mucosal erosions and ulcers; viral inclusion bodies in cell nuclei on biopsy

 Drug-induced esophagitis: Some medications may cause esophageal mucosal irritation, leading to erosions and ulcers

 Causes:

 Antibiotics (e.g., tetracycline, doxycycline, and clindamycin)

 Anti-inflammatory drugs (e.g., Aspirin)

 Bisphosphonates (e.g., Alendronate)

 Others (e.g., potassium chloride, quinidine, and iron compounds)

 Endoscopic findings: punched-out ulcers with mild inflammatory changes of the surrounding mucosa

 Eosinophilic esophagitis

 Associated with allergic disease (allergic asthma, allergic rhinitis) in 50% of cases

 Endoscopic findings

 Circumferential mucosal lesions (rings/corrugations)

 Mucosal fragility

 Histological finding: increased number of eosinophils

2 Conditions not involving esophagitis

 Cardiac: See differential diagnosis of chest pain (especially angina pectoris)

 Gastrointestinal

 Diffuse esophageal spasm

 Achalasia

 Osteochondrosis

 Da Costa's syndrome (or neurocirculatory asthenia)

IX/ Treatment

1 Lifestyle modifications

 Dietary

 Small portions; avoid eating (< 3 hours) before bedtime

 Avoid foods with high fat content

 Physical

 Normalize body weight

 Elevate the head of the bed for patients with nighttime symptoms

 Avoid toxins: nicotine, alcohol, coffee [13][7] , and certain drugs (e.g., calcium channel blockers, diazepam)

2 Medical therapy

 Treatment of choice: Standard-dose of PPI for at least 8 weeks (once daily therapy)

 No response: further diagnostic evaluation

 Partial response: increase the dose (to twice daily therapy) or switch to a different PPI

 Good response: discontinue PPI after 8 weeks

 Maintenance therapy: if symptoms recur after discontinuation of PPIs and in the case of complications (see “Complications” below)

 After 8 weeks of initial treatment, reduce PPI to lowest effective dose or switch to H2RAs (only in patients without complications!)

3 Surgical therapy

 Indications

 Equally effective alternative to medical therapy in certain patients with chronic GERD

 Complications (e.g., Barrett's esophagus, strictures, recurrent aspiration)

 Fundoplication

 Symptoms resolve in 85% of cases, but recurrence is possible

 Technique: The gastric fundus is wrapped around the lower esophagus and secured with stitches to form a cuff, leading

to a narrowing of the distal esophagus and the gastroesophageal junction (GEJ)and prevents reflux

 Nissen fundoplication (= complete fundoplication)

 Complications

 Intraoperative damage to the stomach and/or surrounding organs, especially the esophagus, spleen, lungs/pleura (→ pneumothorax)

 Gas bloat syndrome: inability to belch, leading to bloating and an increase in flatulence

 Dysphagia (especially to solids)

 Telescope phenomenon ("slipped Nissen"): the esophagus slides out of the wrapped stomach portion

 Gastric denervation: Vagal nerve injury leads to bloating and cardiac complaints, resembling Roemheld syndrome

 If hiatal hernia is present [19]

 Hiatoplasty: margins of the widened hiatus are sutured together

 Fundopexy or gastropexy: the protruding part of the stomach is tethered to the diaphragm → keeps it in place and relieves the tension placed on the cuff

X/ Complications

 Reflux esophagitis: most common complication of GERD

 Iron deficiency anemia: mucosal erosions and ulcerations → chronic bleeding → anemia

 Esophageal stricture: most common sequela of reflux esophagitis

 Clinical features: cause solid food dysphagia

 Diagnostics

 Endoscopy with biopsies: to rule out malignancy and eosinophilic esophagitis

 Treatment

 First-line treatment: dilation with bougie dilator/balloon dilator + proton pump inhibitors in patients with reflux

 In refractory cases (multiple recurrences): steroid injection prior to dilation, endoscopic electrosurgical incision

 Recurrence occurs in the majority of patients; often multiple treatment attempts necessary

 Esophageal ring:

 Schatzki rings at the squamocolumnar junction are the most common type

 Clinical features and management similar to that of an esopahgeal stricture

 Aspiration of gastric contents leads to:

 Aspiration pneumonia

 Chronic bronchitis

 Asthma (exacerbation)

 Laryngitis and hoarseness

 Barrett esophagus

 Pathophysiology

 Reflux esophagitis → stomach acid damages squamous epithelium → squamous epithelium becomes replaced

by columnar epithelium and goblet cells(intestinal metaplasia, Barrett's metaplasia) [3]

 The physiological transformation zone ("Z-line") between squamous and columnar epithelium is shifted upwards

 Pathology

 Short-segment Barrett's esophagus (< 3 cm of columnar epithelium between Z-line and GEJ)

 Long-segment Barrett's esophagus (> 3 cm of columnar epithelium between Z-line and GEJ) → higher cancer risk!

 Complications: precancerous condition for adenocarcinoma (see esophageal cancer)

 Management and surveillance

 Medical treatment with PPIs

 Endoscopy with four-quadrant biopsies at every 2 cm of the suspicious area (salmon colored mucosa)

 If no dysplasia: repeat endoscopy every 3–5 years

 If indefinite for dysplasia: repeat endoscopy with biopsies after 3–6 months of optimized PPI therapy

 If low-grade dysplasia

 Endoscopic therapy of mucosal irregularities

 Alternatively: surveillance every 12 months with biopsies every 1 cm

 If high-grade dysplasia: endoscopic therapy of mucosal irregularities

QUESTION Q1 A 45-year-old woman comes to the physician because of progressive difficulty swallowing solids and liquids over the past 4 months

She has lost 4 kg (9 lb) during this period There is no history of serious illness She emigrated to the US from Panama 7 years ago She does not smoke cigarettes or drink alcohol Cardiopulmonary examination shows a systolic murmur and an S3 gallop A barium

radiograph of the chest is shown Endoscopic biopsy of the distal esophagus is most likely to show which of the following?

A Atrophy of esophageal smooth muscle cells

B Presence of intranuclear basophilic inclusions

C Infiltration of eosinophils in the epithelium

D Absence of myenteric plexus neurons

E Presence of metaplastic columnar epithelium

Q2 A 58-year-old woman comes to the physician because of intermittent painful retrosternal dullness for 4 weeks The pain is recurrent

and occurs when she exerts herself or when she is outside during cold weather She also experiences shortness of breath and palpitations during these episodes The symptoms resolve spontaneously when she stops or sits down for a while Over the past few days, the episodes have increased in frequency She has hypertension, type 2 diabetes mellitus, and osteoarthritis Her left leg was amputated below the knee after a motorcycle accident 25 years ago She is currently waiting for a new prosthesis and walks on crutches Current medications include captopril, glyburide, and ibuprofen She does not smoke or drink alcohol Her pulse is 88/min, respirations are 20/min, and blood pressure is 144/90 mm Hg Cardiac examination shows no abnormalities An x-ray of the chest shows no abnormalities An ECG shows a normal sinus rhythm Serum cardiac markers are within the reference range Which of the following is the most appropriate next step in diagnosis?

A Myocardial perfusion scan under pharmacological stress

B Upper endoscopy

C Coronary angiography

D Echocardiography at rest

E Repeat ECG under treadmill stress

F Magnetic resonance angiography

Q3 A 52-year-old woman comes to the physician because of a 4-day history of painful swallowing and retrosternal pain She was

diagnosed with HIV infection 2 months ago; her medications include tenofovir, emtricitabine, and raltegravir Vital signs are within normal limits Physical examination of the oral cavity shows no abnormalities The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500) Empiric treatment is started Two weeks later, she reports no improvement in symptoms Esophagogastroduodenoscopy is

performed and shows multiple round superficial ulcers in the distal esophagus Which of the following is the most likely underlying cause

of this patient's symptoms?

A Gastroesophageal junction incompetence

B Adverse effect of medication

C Infection with cytomegalovirus

D Degeneration of ganglion cells within the myenteric plexuses

E Diffuse esophageal spasm

F Eosinophilic esophageal infiltrate

G Infection with herpes simplex virus

H Infection with Candida species

Q4 A 45-year-old woman comes to the physician because of a 5-month history of recurrent retrosternal chest pain that often wakes her

up at night Physical examination shows no abnormalities Upper endoscopy shows hyperemia in the distal third of the esophagus A biopsy specimen from this area shows non-keratinized stratified squamous epithelium with hyperplasia of the basal cell layer and

neutrophilic inflammatory infiltrates Which of the following is the most likely underlying cause of this patient's findings?

A Increased lower esophageal sphincter tone

B Increased collagen production and fibrosis

C Chronic gastrointestinal iron loss

D Proximal migration of the gastroesophageal junction

E Spread of neoplastic cells

F Metaplastic transformation of the esophageal epithelium

Q5 A 38-year-old man comes to the physician because of an 8-month history of upper abdominal pain During this period, he has also

had nausea, heartburn, and multiple episodes of diarrhea with no blood or mucus He has smoked one pack of cigarettes daily for the past

18 years He does not use alcohol or illicit drugs Current medications include an antacid The abdomen is soft and there is tenderness to palpation in the epigastric and umbilical areas Upper endoscopy shows several ulcers in the duodenum and the upper jejunum as well as

thick gastric folds Gastric pH is < 2 Biopsies from the ulcers show no organisms Which of the following tests is most likely to confirm the diagnosis?

A 24-hour esophageal pH monitoring

B Fasting serum gastrin level

C Urine metanephrine levels

D Urea breath test

E Serum vasoactive intestinal polypeptide level

Q6 A 1-month-old male infant is brought to the physician because of inconsolable crying for the past 3 hours For the past 3 weeks, he

has had multiple episodes of high-pitched unprovoked crying every day that last up to 4 hours and resolve spontaneously He was born at term and weighed 2966 g (6 lb 9 oz); he now weighs 3800 g (8 lb 6 oz) He is exclusively breast fed His temperature is 36.9°C (98.4°F) and pulse is 140/min Examination shows a soft and nontender abdomen The remainder of the examination shows no abnormalities Which of the following is the most appropriate next step in management?

A Perform lumbar puncture

B Administer simethicone

C Administer pantoprazole

D Reassurance

E Recommend the use of Gripe water

Q7 A 58-year-old man comes to the physician for recurrent heartburn for 12 years He has also developed a cough for a year, which is

worse at night He has smoked a pack of cigarettes daily for 30 years His only medication is an over-the-counter antacid He has not seen

a physician for 8 years He is 175 cm (5 ft 9 in) tall and weighs 95 kg (209 lb); BMI is 31 kg/m2 Vital signs are within normal limits There is no lymphadenopathy The abdomen is soft and nontender The remainder of the examination shows no abnormalities A

complete blood count is within the reference range An upper endoscopy shows columnar epithelium 2 cm from the gastroesophageal junction Biopsies from the columnar epithelium show low-grade dysplasia and intestinal metaplasia Which of the following is the most appropriate next step in management?

A Repeat endoscopy in 18 months

B Endoscopic therapy

C Esophagectomy

D Omeprazole, clarithromycin, and metronidazole therapy

E External beam radiotherapy

F Nissen fundoplication

Q8 A 34-year-old man comes to the physician for a follow-up examination He has a 3-month history of a nonproductive cough He has

been treated with diphenhydramine since his last visit 2 weeks ago, but his symptoms have persisted He does not smoke He drinks 3 beers on the weekends He is 177 cm (5 ft 10 in) tall and weighs 100 kg (220.46 lbs); BMI is 35.1 kg/m2 His temperature is 37.1°C (98.8°F), pulse is 78/min, respirations are 14/min, and blood pressure is 130/80 mm Hg Pulse oximetry on room air shows an oxygen saturation of 97% Physical examination and an x-ray of the chest show no abnormalities Which of the following is the most appropriate next step in management?

A Azithromycin therapy

B Pulmonary function testing

C Omeprazole therapy

D Tuberculin skin test

E Oral corticosteroid therapy

F CT scan of the chest

Q9 A 45-year-old man comes to the physician for the evaluation of painful swallowing and retrosternal pain over the past 2 days He was

recently diagnosed with HIV infection, for which he now takes tenofovir, emtricitabine, and raltegravir There is no family history of serious illness He has smoked one pack of cigarettes daily for the past 20 years He drinks 2–3 beers per day He does not use illicit drugs Vital signs are within normal limits Physical examination of the oral cavity shows no abnormalities The patient's CD4+ T-lymphocyte count is 80/mm3 (normal ≥ 500) Empiric treatment is started Two weeks later, he reports no improvement in his symptoms Esophagogastroduodenoscopy is performed and shows multiple well-circumscribed, round, superficial ulcers in the upper esophagus Which of the following is the most likely underlying cause of this patient's symptoms?

A Infection with herpes simplex virus

B Adverse effect of medication

C Transient lower esophageal sphincter relaxation

D Allergic inflammation of the esophagus

E Degeneration of inhibitory neurons within the myenteric plexuses

F Diffuse esophageal spasm

G Infection with Candida species

H Infection with cytomegalovirus

Q10 A 68-year-old man comes to the physician because of recurrent episodes of nausea and abdominal discomfort for the past 4 months

The discomfort is located in the upper abdomen and sometimes occurs after eating, especially after a big meal He has tried to go for a walk after dinner to help with digestion, but his complaints have only increased For the past 3 weeks he has also had symptoms while climbing the stairs to his apartment He has type 2 diabetes mellitus, hypertension, and stage 2 peripheral arterial disease He has smoked

one pack of cigarettes daily for the past 45 years He drinks one to two beers daily and occasionally more on weekends His current medications include metformin, enalapril, and aspirin He is 168 cm (5 ft 6 in) tall and weighs 126 kg (278 lb); BMI is 45 kg/m2 His temperature is 36.4°C (97.5°F), pulse is 78/min, and blood pressure is 148/86 mm Hg On physical examination, the abdomen is soft and nontender with no organomegaly Foot pulses are absent bilaterally An ECG shows no abnormalities Which of the following is the most appropriate next step in diagnosis?

A Esophagogastroduodenoscopy

B CT scan of the abdomen

C CT angiography of the abdomen

D Hydrogen breath test

E Cardiac stress test

F Abdominal ultrasonography of the right upper quadrant

G Endoscopic retrograde cholangiopancreatography

Q11 A 28-year-old man comes to the physician because of a 1-year history of chronic back pain He explains that the pain started after

getting a job at a logistics company He does not recall any trauma and does not have morning stiffness or neurological symptoms He has been seen by two other physicians for his back pain who did not establish a diagnosis The patient also has abdominal bloating and a feeling of constipation that started 3 weeks ago After doing extensive research on the internet, he is concerned that the symptoms might

be caused by pancreatic cancer He would like to undergo a CT scan of his abdomen for reassurance He has a history of episodic chest pain, for which he underwent medical evaluation with another healthcare provider Tests showed no pathological results He does not smoke or drink alcohol He reports that he is under significant pressure from his superiors due to frequent performance evaluations He takes daily multivitamins and glucosamine to prevent arthritis His vital signs are within normal limits Examination shows a soft, non-tender, non-distended abdomen and mild bilateral paraspinal muscle tenderness The remainder of the examination, including a

neurologic examination, shows no abnormalities Laboratory studies are within the reference range An x-ray of the spine shows no abnormalities Which of the following is the most likely explanation for this patient's symptoms?

A Adjustment disorder

B Malignant neoplasm

C Illness anxiety disorder

D Atypical depression

E Irritable bowel syndrome

F Conversion disorder

G Somatic symptom disorder

H Acute stress disorder

Q12 A 58-year-old man comes to the physician for the evaluation of intermittent dysphagia for 6 months He states that he drinks a lot of

water during meals to help reduce discomfort he has while swallowing food He has hypertension and gastroesophageal reflux disease

He has smoked one half-pack of cigarettes daily for 32 years He does not drink alcohol Current medications include hydrochlorothiazide and ranitidine He is 173 cm (5 ft 8 in) tall and weighs 101 kg (222 lb); BMI is 33.7 kg/m2 His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 125/75 mm Hg The lungs are clear to auscultation Cardiac examination shows no murmurs, rubs, or gallops The abdomen is soft and nontender A barium esophagogram shows complete obstruction at the lower end of the esophagus with

an irregular filling defect An upper endoscopy shows a sliding hiatal hernia and a constricting ring at the gastroesophageal junction Biopsies from the lesion show squamocolumnar epithelium with no metaplasia Which of the following is the most appropriate next step

in the management of this patient?

A Esophagectomy

B Esophageal stent

C Intralesional corticosteroid

D Iron supplementation

E Omeprazole therapy

F Nissen fundoplication

G Mechanical dilation

Q13 A 68-year-old man comes to the physician because of a 4-month history of bad breath and progressive difficulty swallowing solid

food Physical examination shows no abnormalities An upper endoscopy is performed and a photomicrograph of a biopsy specimen obtained from the mid-esophagus is shown Which of the following best explains the findings in this patient?

A Well-differentiated neoplastic glandular proliferation

B Atrophy and fibrosis of the esophageal smooth muscle

C Metaplastic transformation of esophageal mucosa

D Neoplastic proliferation of squamous epithelium

E Eosinophilic infiltration of the esophageal walls

Q14 A previously healthy 37-year-old man comes to the physician for the evaluation of a 8-week history of intermittent burning

epigastric pain During this period, he has also felt bloated and uncomfortable after meals He has not had weight loss or a change in bowel habits He has no personal or family history of serious illness He takes no medications He does not smoke He drinks 1–3 beers per week Vital signs are within normal limits Abdominal examination shows mild epigastric tenderness on palpation without guarding

or rebound tenderness Bowel sounds are normal The remainder of the examination shows no abnormalities Which of the following is the most appropriate next step in management?

A Urea breath test

B Helicobacter pylori eradication therapy

C Helicobacter pylori serum IgG

D Proton pump inhibitors

E Upper gastrointestinal endoscopy

F Abdominal ultrasonography

Q15 A 60-year-old woman comes to the physician because of a 2-week history of severe, retrosternal chest pain She also has pain when

swallowing solid food and medications She has hypertension, type 2 diabetes mellitus, poorly-controlled asthma, and osteoporosis She was recently admitted to the hospital for an acute asthma exacerbation that was treated with bronchodilators and a 7-day course of oral corticosteroids Her current medications include aspirin, amlodipine, metformin, insulin, beclomethasone and albuterol inhalers, and alendronate Vital signs are within normal limits Examination of the oral pharynx appears normal The lungs are clear to auscultation An upper endoscopy shows a single punched-out ulcer with normal surrounding mucosa at the gastroesophageal junction Biopsies of the ulcer are taken Which of the following is the most appropriate next step in management?

A Start ganciclovir

B Discontinue alendronate

C Start nystatin

D Start pantoprazole

E Discontinue amlodipine

F Start fluconazole

Q16 A 37-year-old man comes to the physician because of a 1-month history of a burning sensation in his chest The sensation is most

prominent when he is lying in bed, but it is also present after eating heavy meals He also states his breath has an unpleasant odor in the morning He has not lost any weight during this period He has hypothyroidism His father died of colon cancer and his mother has hypertension He has smoked one pack of cigarettes daily for 15 years and drinks 2–3 beers on weekends His medications include levothyroxine and an over-the-counter multivitamin He is 170 cm (5 ft 7 in) tall and weighs 95 kg (210 lb); BMI is 32.9 kg/m2 Vital signs are within normal limits Physical examination shows no abnormalities Which of the following is the next best step in

management?

A Esophagogastroduodenoscopy

B Urea breath test

C Proton-pump inhibitor

D H2 receptor blocker

E Barium swallow

F Amoxicillin and clarithromycin

G Calcium carbonate

Q17 A previously healthy 55-year-old man comes to the physician because of a 5-month history of progressively worsening substernal

chest pain after meals The pain occurs almost daily, is worst after eating spicy food or drinking coffee, and often wakes him up from sleep at night He has not had any weight loss He has smoked 1 pack of cigarettes daily for 35 years and he drinks 1 to 2 glasses of wine daily with dinner Physical examination is unremarkable Esophagogastroduodenoscopy shows erythema of the distal esophagus with two small mucosal erosions Biopsy specimens obtained from the esophagus show no evidence of metaplasia Without treatment, this patient

is at greatest risk for which of the following complications?

A Esophageal adenocarcinoma

B Esophageal squamous cell carcinoma

C Laryngeal carcinoma

D Esophageal stricture

E Sliding hiatal hernia

F Pyloric stenosis

Q18 A 36-year-old woman comes to the physician because of a 12-month history of upper abdominal pain The pain is worst after

eating, when it is 7 out of 10 in intensity During this period she has also had nausea, heartburn, and multiple episodes of diarrhea with no blood or mucus Eight months ago, she underwent an upper endoscopy, which showed several ulcers in the gastric antrum, the pylorus, and the duodenum, as well as thick gastric folds The biopsies from these ulcers were negative for H pylori Current medications include pantoprazole and over-the-counter antacids She appears anxious Vital signs are within normal limits Cardiopulmonary examination shows no abnormalities The abdomen is soft and there is tenderness to palpation in the epigastric and umbilical areas Test of the stool

for occult blood is positive A repeat upper endoscopy shows persistent gastric and duodenal ulceration with minimal bleeding Which of the following is the most appropriate next step in diagnosis?

A Secretin stimulation test

B Urea breath test

C 24-hour esophageal pH monitoring

D Fasting serum gastrin level

E CT scan of the abdomen and pelvis

Q19 Three days after undergoing open surgery to repair a bilateral inguinal hernia, a 66-year-old man has new, intermittent upper

abdominal discomfort that worsens when he walks around He also has new shortness of breath that resolves with rest There were no complications during surgery or during the immediate postsurgical period Ambulation was restarted on the first postoperative day He has type 2 diabetes mellitus, hypercholesterolemia, asthma, and hypertension He has smoked one pack of cigarettes daily for 25 years Prior to admission, his medications included metformin, simvastatin, an albuterol inhaler, and lisinopril His temperature is 37°C

(98.6°F), pulse is 80/min, respirations are 16/min, and blood pressure is 130/80 mm Hg Pulse oximetry on room air shows an oxygen saturation of 98% The abdomen is soft and shows two healing surgical scars with moderate serous discharge Cardiopulmonary

examination show no abnormalities ECG at rest shows no abnormalities Cardiac enzyme levels are within the reference range An x-ray

of the chest and abdominal ultrasonography show no abnormalities Which of the following is the most appropriate next step in

diagnosis?

A Serum D-dimer level

B Magnetic resonance imaging of the abdomen

C Spirometry

D Cardiac exercise stress test

E Culture swab from the surgical site

F Coronary angiography

G Magnetic resonance angiography of the thorax

H Cardiac pharmacological stress test

I Esophagogastroduodenoscopy

Q20 A 56-year-old man comes to the physician because of intermittent retrosternal chest pain Physical examination shows no

abnormalities Endoscopy shows salmon pink mucosa extending 5 cm proximal to the gastroesophageal junction Biopsy specimens from the distal esophagus show nonciliated columnar epithelium with numerous goblet cells Which of the following is the most likely cause of this patient's condition?

A Neoplastic proliferation of esophageal epithelium

B Esophageal exposure to gastric acid

C Atopic inflammation of the esophagus

D Hypermotile esophageal contractions

E Fungal infection of the lower esophagus

F Incomplete relaxation of lower esophageal sphincter

ANSWER:

16C 17D 18D 19H 20B