GI PBL

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Questions and Answers

What is the primary purpose of performing an endoscopic ultrasound (EUS) with fine needle aspiration in cases suspected of achalasia?

To measure the pressure in the lower esophageal sphincter

To evaluate the motility of the esophagus

To visualize the entire digestive tract

To definitively rule out pseudoachalasia and cancer (correct)

Which histological feature is primarily associated with classic achalasia?

Increased ganglion cells in the myenteric plexus

Presence of atypical tumor cells in the biopsy

Significant loss of ganglion cells from the myenteric plexus (correct)

Inflammation of smooth muscle fibers

What is the main goal of performing a Dor fundoplication following laparoscopic Heller myotomy?

To create a high-pressure valve at the lower esophageal sphincter

To completely eliminate all esophageal motility

To prevent reflux from the stomach into the esophagus (correct)

To enhance the muscular layer of the distal esophagus

In the biopsy specimens, what indicates the presence of ganglionitis?

Presence of lymphocytic infiltration into ganglion cell cytoplasm Signup and view all the answers

What characterizes the later stage of the disease process reflected in the lower panel of the biopsy specimens?

Significant scarring within the peripheral nerve and loss of ganglion cells Signup and view all the answers

Which statement accurately describes the role of esophagogastroduodenoscopy (EGD) in the diagnosis process for achalasia?

EGD provides images that help differentiate between achalasia and pseudoachalasia. Signup and view all the answers

What additional diagnostic test is commonly performed after EGD if achalasia is suspected?

High-resolution esophageal manometry Signup and view all the answers

Which statement accurately differentiates achalasia from pseudoachalasia?

Achalasia is a primary disorder, while pseudoachalasia arises from other conditions. Signup and view all the answers

What is the purpose of using small forceps during an EGD?

To perform biopsies by excising tissue samples. Signup and view all the answers

What is the significance of the integrated relaxation pressure (IRP) in esophageal manometry?

It summarizes the relaxation of the lower esophageal sphincter. Signup and view all the answers

Which of the following abnormalities would be indicative of achalasia during a barium swallow X-ray?

Delayed emptying of the esophagus Signup and view all the answers

How does the pressure topography (Clouse) plot differ in individuals with achalasia compared to those with normal function?

It indicates significantly decreased relaxation pressures at the LES. Signup and view all the answers

What is the most likely outcome if EGD results are suggestive of pseudoachalasia?

Additional tests, such as manometry and X-ray, are needed to clarify the diagnosis. Signup and view all the answers

What characteristic feature can be noted in the manometry recording of a patient with normal esophageal function?

Normal pattern of peristalsis and LES relaxation. Signup and view all the answers

What is the primary condition diagnosed for Mr. Pham based on his symptoms?

Achalasia Signup and view all the answers

Which of the following is NOT a symptom associated with Mr. Pham's condition?

Regular bowel movements Signup and view all the answers

How does pantoprazole relieve symptoms of heartburn in a patient like Mr. Pham?

By blocking the gastric proton pump Signup and view all the answers

Which of the following factors could contribute to Mr. Pham's worsening symptoms if left unchanged?

Irregular eating habits Signup and view all the answers

The absence of which cells leads to impaired function of the lower esophageal sphincter in achalasia?

Ganglion cells Signup and view all the answers

Which condition might mimic Mr. Pham’s heartburn but is specifically characterized by the movement of stomach acid into the lower esophagus?

Gastroesophageal reflux disease (GERD) Signup and view all the answers

What key dietary recommendation was made to Mr. Pham during his initial visit?

Eat three regular meals a day Signup and view all the answers

Which of the following symptoms would suggest a potential reassessment of Mr. Pham's diagnosis?

Occasional regurgitation of food Signup and view all the answers

What characteristic feature is observed in the esophagus during a barium swallow x-ray in a patient with achalasia?

Bird-beak appearance at the junction Signup and view all the answers

Which neurotransmitter is released by the preganglionic vagus nerve fibers in the distal esophagus?

Acetylcholine Signup and view all the answers

What happens to the ganglion cells of the myenteric plexus in patients with achalasia?

Reduction or absence of inhibitory neurons Signup and view all the answers

What is the primary cause of ganglion cell loss in achalasia as discussed?

Chronic ganglionitis Signup and view all the answers

Which mechanism does NOT contribute to LES relaxation?

Extrinsic innervation from sympathetic fibers Signup and view all the answers

What condition may be ruled out through an esophageal biopsy in patients suspected to have achalasia?

Esophageal cancer or pseudoachalasia Signup and view all the answers

In terms of esophageal motility, which statement about achalasia is true?

Loss of peristalsis arises from ganglion cell abnormalities Signup and view all the answers

What is a common manifestation of esophageal motility disorder seen in achalasia?

Dysphagia due to impaired LES relaxation Signup and view all the answers

What typical esophageal manometry recording is observed in patients with achalasia?

Absence of the peristaltic wave activity Signup and view all the answers

What is indicated by the absence of high-pressure boluses in Mr. Pham's recording compared to a normal esophagus?

Uniform pressure along the esophagus. Signup and view all the answers

Which statement best describes the function of the lower esophageal sphincter (LES) during normal swallowing?

The LES relaxes to allow the passage of the food bolus. Signup and view all the answers

What is the primary characteristic of achalasia as observed in Mr. Pham's manometry results?

Uniform pressure readings along the esophagus. Signup and view all the answers

What role do the inner circular and outer longitudinal muscle layers play during peristalsis?

They contract in a coordinated fashion. Signup and view all the answers

What is the maximum number of pressure sensors used in high-resolution esophageal manometry?

36 sensors Signup and view all the answers

In Mr. Pham's case, what is lacking in the pressure plots that would normally indicate normal esophageal function?

Evidence of peristalsis. Signup and view all the answers

What features characterize the tracing mode recording in Mr. Pham’s esophageal manometry results?

Similar uniform pressure readings. Signup and view all the answers

What typically happens to esophageal pressure just behind the food bolus during normal swallowing?

It increases to create high pressure. Signup and view all the answers

What does the high-resolution pressure topography plot illustrate during esophageal manometry?

The pattern and pressures of muscle contractions in the esophagus. Signup and view all the answers

Study Notes

Mr. Pham's Case Study

Goal: To understand normal body structure and function related to heartburn.
Diagnosis: Achalasia. A disorder where ganglion cells in the esophageal myenteric plexus are reduced or absent. This leads to loss of peristalsis and impaired lower esophageal sphincter (LES) relaxation.
Initial Symptoms: Persistent heartburn not relieved by antacids, chest pain (especially after eating), trouble sleeping, irregular eating habits.
Initial Diagnosis: GERD (Gastroesophageal Reflux Disease) due to insufficient acid suppression, as eating before bed increases supine acid exposure.
Treatment: Prescribed pantoprazole (Protonix), a proton pump inhibitor (PPI) to reduce gastric acid production.
Follow-up Symptoms: Worsening chronic cough, difficulty swallowing (dysphagia), regurgitation, weight loss (10 pounds).
New Diagnosis: Achalasia, suggested by follow-up symptoms and EGD results.
EGD (Esophagogastroduodenoscopy): Procedure using a flexible endoscope to visualize and examine the esophagus.
Procedure Confirmation: High-resolution esophageal manometry and barium swallow X-ray to confirm the diagnosis of Achalasia.
Manometry: Measures pressures and muscle contractions in the esophagus during swallowing. Shows lack of peristaltic waves and impaired LES relaxation.
Barium Swallow: X-ray using barium sulfate to visualize abnormalities in upper gastrointestinal tract (esophagus, stomach, duodenum); shows a narrowing of the LES.
Biopsy: Esophageal biopsy rules out cancer/pseudoachalasia. The biopsy shows inflammation of the nerve tissue (ganglionitis) in the esophagus.
Treatment for Achalasia: Laparoscopic Heller myotomy—minimally invasive procedure that opens the lower esophageal sphincter (LES). This is done by cutting the smooth muscle of the sphincter. This is frequently combined with a Dor fundoplication, a procedure which wraps the stomach around the esophagus to create a lower pressure valve and prevent reflux.
Achalasia Pathophysiology: Loss of ganglion cells in the esophageal myenteric plexus compromises peristalsis and LES relaxation.

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Description

This quiz explores a case study focusing on heartburn, with an emphasis on the diagnosis and treatment of achalasia. Participants will learn about the symptoms, initial diagnosis of GERD, and the eventual treatment strategy involving proton pump inhibitors. Test your understanding of gastrointestinal disorders and their management.