Oesophagus & dysphagia flashcards
22 high-yield MRCP Part 1 cards from the Intellect Medicos Gastroenterology & Hepatology course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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In achalasia the initial investigation is a ______, and the gold-standard diagnostic test is oesophageal manometry.
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barium swallow
Why? Barium shows a dilated oesophagus tapering to a 'bird's beak'. Manometry proves the failure of LES relaxation and absent peristalsis.
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In achalasia the initial investigation is a barium swallow, and the gold-standard diagnostic test is ______.
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oesophageal manometry
Why? Barium shows a dilated oesophagus tapering to a 'bird's beak'. Manometry proves the failure of LES relaxation and absent peristalsis.
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What is the underlying neuronal defect in achalasia?
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Loss of inhibitory neurons in the myenteric (Auerbach's) plexus, so less nitric oxide and VIP are released.
Why? Without these inhibitory signals the lower oesophageal sphincter cannot relax and peristalsis is lost.
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What is the main serious complication of pneumatic balloon dilatation for achalasia?
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Oesophageal perforation.
Why? Forceful stretching of the LES can tear the oesophageal wall. Dilatation, laparoscopic Heller myotomy (with partial fundoplication) and POEM are all accepted definitive treatments, chosen by patient factors and local expertise.
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Which treatment for achalasia suits an elderly patient who is a poor candidate for dilatation or surgery?
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Botulinum toxin injection into the lower oesophageal sphincter.
Why? Botulinum toxin blocks acetylcholine release and lowers LES pressure. It is safe but the effect wears off within months, so it is kept for frail patients.
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Barrett's oesophagus is replacement of the normal distal ______ epithelium by ______ epithelium.
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stratified squamous; metaplastic columnar
Why? Chronic acid reflux drives this metaplasia. It is the precursor of oesophageal adenocarcinoma.
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NICE surveillance endoscopy for non-dysplastic Barrett's oesophagus: segment under 3 cm WITH intestinal metaplasia every ______; segment 3 cm or longer every 2–3 years.
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3–5 years
Why? Longer segments carry a higher cancer risk, so they are scoped more often. Use high-resolution white-light endoscopy with Seattle-protocol biopsies, and tailor the interval to age, sex, family history and smoking.
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NICE surveillance endoscopy for non-dysplastic Barrett's oesophagus: segment under 3 cm WITH intestinal metaplasia every 3–5 years; segment 3 cm or longer every ______.
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2–3 years
Why? Longer segments carry a higher cancer risk, so they are scoped more often. Use high-resolution white-light endoscopy with Seattle-protocol biopsies, and tailor the interval to age, sex, family history and smoking.
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What is offered for confirmed LOW-grade dysplasia in Barrett's oesophagus?
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Endoscopic radiofrequency ablation (RFA).
Why? RFA destroys the dysplastic lining and lowers progression to cancer.
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What is the first-line treatment for HIGH-grade dysplasia in Barrett's oesophagus?
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Endoscopic resection (of any visible lesion), followed by ablation of the remaining Barrett's segment.
Why? Endoscopic therapy removes the dysplasia while sparing the oesophagus. Ongoing endoscopic follow-up is still needed because dysplasia can recur.
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What is the first-line investigation for a suspected pharyngeal pouch?
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Barium swallow, done before any endoscopy.
Why? The endoscope can enter the pouch and perforate it, so the anatomy is defined with contrast first.
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What oesophageal biopsy finding defines eosinophilic oesophagitis?
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15 or more eosinophils per high-power field.
Why? Endoscopy may show rings ('trachealisation'), linear furrows and white exudates, but the diagnosis rests on biopsy.
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Which drug treatment is used in eosinophilic oesophagitis that does not respond fully to a PPI?
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A swallowed topical corticosteroid, e.g. budesonide (orodispersible) or fluticasone.
Why? Topical steroid acts directly on the oesophageal mucosa with little systemic effect.
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A man with HIV (CD4 count 120) has painful swallowing. Endoscopy shows white adherent plaques that cannot be washed off. What is the first-line treatment?
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Oral fluconazole.
Why? This is oesophageal candidiasis. Unlike oral thrush, it needs a systemic azole, not topical nystatin.
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What is the mechanism of action of proton pump inhibitors?
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Irreversible inhibition of the H+/K+ ATPase (proton pump) in gastric parietal cells.
Why? This blocks the final common step of acid secretion, so acid falls whatever the stimulus (gastrin, histamine or vagal).
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Which electrolyte disturbance is a recognised effect of long-term PPI use?
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Hypomagnesaemia.
Why? PPIs reduce intestinal magnesium absorption. Severe cases cause tetany, arrhythmias and secondary hypocalcaemia or hypokalaemia.
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Name two drug classes that worsen gastro-oesophageal reflux.
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Any two of: calcium-channel blockers, nitrates, anticholinergics.
Why? They relax the lower oesophageal sphincter, allowing acid to reflux.
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After a night of heavy drinking and forceful vomiting, a 45-year-old man has severe retrosternal pain. There is crepitus in his neck. What is the gold-standard investigation?
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Water-soluble contrast (Gastrografin) swallow.
Why? This is Boerhaave's syndrome (Mackler's triad: vomiting, chest pain, subcutaneous emphysema). Chest X-ray is the initial test; contrast confirms the leak.
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Oesophageal adenocarcinoma arises in the ______ and is linked to GORD, Barrett's and obesity; squamous cell carcinoma arises in the upper and middle oesophagus and is linked to smoking, alcohol, achalasia and Plummer–Vinson.
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distal oesophagus / GO junction
Why? Reflux-driven metaplasia happens at the lower end, whereas carcinogens in smoke and alcohol act along the whole squamous lining.
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Oesophageal adenocarcinoma arises in the distal oesophagus / GO junction and is linked to GORD, Barrett's and obesity; squamous cell carcinoma arises in the ______ oesophagus and is linked to smoking, alcohol, achalasia and Plummer–Vinson.
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upper and middle
Why? Reflux-driven metaplasia happens at the lower end, whereas carcinogens in smoke and alcohol act along the whole squamous lining.
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Which investigation gives the best LOCOREGIONAL staging (T and N stage) of oesophageal cancer?
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Endoscopic ultrasound (EUS).
Why? EUS shows the depth of invasion through the wall layers and nearby nodes. CT chest/abdomen/pelvis (± PET-CT) looks for distant spread.
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Under NICE NG12, which people with dysphagia should be referred on a suspected cancer pathway for oesophageal cancer?
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Anyone with dysphagia, at any age.
Why? Dysphagia is a red flag for oesophageal cancer. Other red flags on the slide: progressive dysphagia, odynophagia, weight loss, iron deficiency anaemia, and age over 55 with new symptoms.
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