A 75-year-old male presents to the clinic with a feeling of fullness in his throat and trouble swallowing.
He complains of a worsening cough and more rec... [Show More] ently, bad breath to the point he avoids going out in
public. What is the most appropriate first diagnostic test?
A. Plain chest x-ray
B. Barium esophageal
C. Upper endoscopy
D. Manometry
E. CT of the chest - Barium esophageal
Correct.
This patient presents with classic symptoms of Zenker's diverticulum, which is most commonly found
in elderly patients and is believed to be the result of loss of tissue elasticity and muscle tone
associated with aging. It is found herniating into Killian's triangle, located at the junction of the
hypopharynx and the esophagus. The most appropriate first diagnostic test would be a barium
esophageal, especially lateral views since it is usually found posteriorly alongside the esophagus.
Upper endoscopy and manometry are not necessary in diagnosing Zenker's.
A 50-year-old male presents to the ER with chest pain 6 hours after undergoing pneumatic dilation for
achalasia. A water-soluble contrast UGI demonstrates a small well-contained perforation. The distal
esophagus appears patent. The patient is hemodynamically stable. What is the next best step in
management?
A. Observe and attempt PO trial.
B. Admit, keep NPO and start broad-spectrum antibiotics.
C. Placement of a CT-guided mediastinal drain
D. Immediate operative debridement
E. Discharge patient with close follow-up. - Admit, keep NPO and start broad-spectrum antibiotics.
Correct.
Most iatrogenic esophageal perforations secondary to pneumatic dilation are small and wellcontained. The patient should be initially considered for non-operative management with antibiotics
and close monitoring based on the aforementioned UGI findings if the distal obstruction has been
resolved and the patient remains hemodynamically stable. Development of concerning signs may
ultimately warrant intervention such as CT-guided drainage or operative management. Attempting PO
trial or discharge would be inappropriate and premature at this time.
A 35-year-old male presents to the ER complaining of chest pain. He went out to dinner 2 nights ago
and rapidly developed abdominal cramps, emesis and diarrhea; however, he did not notice blood in
his vomit or stools. This morning he woke up with acute onset of 10/10 chest pain and described
feeling lightheaded and dizzy. He denies any recent alcohol use. Current vital signs are: HR 120
bpm, BP 100/68 mmHg, R 24/min and T 101.6°F. Which test is most likely to identify the diagnosis?
A. EKG
B. Flat plate and upright of the abdomen
C. Esophageal
D. Stool pathogens
E. Urea breath test - Esophageal
Correct.
The correct diagnosis is spontaneous esophageal perforation, or Behave syndrome. The stem
identifies a recent episode of food poisoning with significant emesis. Although this patient doesn't
drink, alcoholism and binge drinking with emesis is another red flag for esophageal spontaneous
perforation. Contrast esophagram is the test most likely to identify the diagnosis. CT scan, although
not listed, is also helpful. EKG would be helpful to identify a cardiac etiology such as MI, but in our
patient would likely just show sinus tachycardia. Abdominal series would help diagnose bowel
obstruction or pneumoperitoneum from a hollow viscus perforation. Stool pathogen may be positive
given recent gastroenteritis; however, this is not the cause of delayed sepsis. Urea breath test is used
to diagnose H. pylori related to peptic ulcer disease.
A 45-year-old male presents to the ER complaining of nausea and vomiting. He smells of alcohol and
notes a change in emesis from bilious to bloody acutely this evening. Upon further questioning, he
admits to binge drinking often to the point of vomiting. His current vitals are: HR 110 bpm, BP 120/74
mmHg, R 22/min and T 99.3°F. What is the likely cause of his symptoms?
A. Peptic ulcer disease
B. Esophageal varices
C. Esophageal perforation
D. Esophageal cancer
E. Mallory-Weiss syndrome - Mallory-Weiss syndrome
Correct.
The patient has Mallory-Weiss syndrome. From his history, he appears to be an alcoholic on a recent
binge. Although the differential for upper GI bleeding and emesis is broad, bilious emesis which
acutely changes to bloody emesis is highly suggestive of a Mallory-Weiss tear, which occurs at the
junction of the esophagus and gastric cardia. Cancer is likely to have a more indolent obstructive
presentation. Perforation often presents with tachycardia, leukocytosis and fever.
A 42-year-old otherwise healthy female was noted to have persistent UGI bleeding following an
episode of severe vomiting. Endoscopic evaluation notes a mucosal tear in the gastric cardia.
Multiple endoscopic attempts fail to control the bleeding. The patient is now hemodynamically
unstable. What is the next step in management?
A. Octreotide
B. Continuous proton pump inhibitor
C. Repeat attempt at endoscopic electrocoagulation
D. Angiographic embolization
E. Oversewing laceration through an anterior gastrostomy - Oversewing laceration through an
anterior gastrostomy
Correct.
Mallory-Weiss tears are often caused by forceful retching or coughing. Similar to other sources of
UGI bleeding, initial treatment typically consists of non-operative medical management and
endoscopic maneuvers. However, in cases of persistent bleeding and concurrent hemodynamic
instability, operative intervention is warranted. The mucosal tear is typically located in the gastric
cardia and can be accessed through an anterior gastrostomy. Continued medical therapy would not
be appropriate at this time. Angiographic embolization can be utilized in cases when patients are not
suitable or unwilling to undergo surgery.
A 1-year-old child presents to the emergency room after having swallowed a penny. At which level of
the esophagus is the coin most likely to become lodged?
A. Cervical esophagus
B. Mid esophagus
C. GE junction
D. Level of the aortic arch - Cervical esophagus
Correct.
Most objects remain in the cervical esophagus at a natural point of narrowing.
A 75-year-old female is brought into the ER by EMS from a local nursing home after complaining of
throat pain and difficulty swallowing that started after eating roasted chicken 2 days ago. She has
mild dementia but is otherwise healthy. Overnight, she becomes febrile with a temperature of
102.4°F. On physical exam, she has subcutaneous crepitus in the right and left cervical regions. She
has an irregularly irregular HR in the 120s and a BP of 105/65 mmHg. She is made NPO and IV fluids
are started. What is the next best step in managing this patient?... [Show Less]
