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1. A 45 year old woman with no significant past medical history presents with a three month history of worsening dysphagia, heartburn, and chest pain. Physical exam reveals a thin woman with a normal oropharynx and abdominal exam. She has been treated by her primary care physician with antireflux medications for 8 weeks, which has provided no relief. An upper gastrointestinal series (UGI) was performed and a representative view is shown below.
Which of the following additional studies/management strategy would be indicated at this time. (Select all correct answers.)
a) Esophageal manometry b) Esophagogastroscopy c) 24 hour pH monitoring d) CT scan of the chest e) Begin proton pump inhibitor with follow-up in three months
2. Esophageal manometry as well as esophagogastroscopy was performed. Manometry revealed incomplete LES relaxation, aperistalsis in the esophageal body, and elevated LES resting pressure (<26mmHg.) Esophagogastroscopy showed narrowing one centimeter proximal to the gastroesophageal junction. (Picture below.)
No mucosal lesions were identified and the endoscopist was able to advance the scope through the narrowing. The most likely diagnosis given this information is which of the following?
a) Severe GERD with Barrett's esophagitis b) Diffuse esophageal spasm c) Non-specific esophageal motility disorder d) Achalasia e) Esophageal carcinoma f) Don't Know
3. Achalasia is a rare dismotility disorder of the esophagus thought to be due to the loss or destruction of ganglion cells in the myenteric plexus. Proposed mechanisms to explain the pathophysiology of achalasia include all of the following except:
a) Class II HLA antigen DQw1 b) Autoimmune process characterized by antibodies targeted at neurons in the myenteric plexus c) Measles viral infection d) Herpes zoster viral infection e) All of the above have been reported in the literature f) Don't Know
4. Which of the following management options would be indicated for this patient?
a) Continue PPI therapy with repeat endoscopy in 8 weeks b) Repeated endoscopic esophageal dilatation c) Calcium channel blocker therapy d) Repeated injection of botulinum toxin e) Esophageal pneumaticdilatation followed by surgical myotomy if symptoms of dysphagia continue f) Don't Know
5. Which of the following surgical procedures would be indicated at this time?
a) Transabdominal (open) Heller myotomy b) Transthoracic (open) Heller myotomy c) Thoracoscopic Heller myotomy d) Laparoscopic Heller myotomy e) The correct answer is controversial. All are acceptable. f) Don't Know
6. You choose to do a laparoscopic Heller myotomy. The following laparoscopic views were obtained.
Endoscopy was utilized during the procedure to assess the length of the myotomy and to rule out concomitant perforation of the esophagus. No perforation was detected and the myotomy was extended two centimeters past the GE junction. Based on a review of current literature concerning the need for fundoplication and the extent of myotomy, all of the following statements are true except:
a) Postoperative results with regards to the absence of symptomatic reflux are superior for Heller myotomy with a concomitant fundoplication especially when an open transabdominal approach is employed. b) The type of fundoplication employed minimally influences postoperative results. c) The length over which the gastric myotomy is extended appears to be important only if the fundoplication is omitted. d) Minimally invasive techniques have shown satisfactory results in short-term follow up. e) Controversies abound concerning the best surgical treatment of achalasia. All of the above answers are correct. f) Don't Know
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