Q1. Which of the feature seen on endoscopy of the oesophagus is not correct?
a) Columnar epithelium is reddish, with coarse texture as compared to squalors epithelium which is pale and glossy.
b) The squamocolumnar junction is normally within 2 cm of the gastroesophageal junction.
c) If columnar epithelium without metaplasia is seen distant from the gastroesophageal junction, this is suggestive of Barrett's oesophagus
d) Short segment Barrett's oesophagus is when the columnar segment is less than 3 cm.
Q2. Which of the following dyes are not used in chromoendoscopy?
a) Potassium Iodide
b) Congo Red
c) Methylene blue
d) Cresyl Violet
Q3. Which of the following is not an indication for surgery in GERD?
a) Young Age with symptoms controlled on proton pump inhibitors.
b) Progressive respiratory symptoms
c) Barrett's oesophagus
d) Hiatus hernia with symptoms controlled on medicines
Q 4. Which of the following conditions in GERD have the word response after Surgery, (Fundoplication)?
a) Atypical GERD symptoms
b) Patients who achieve symptomatic pain relief with PPIs
c) Classical GERD symptoms
d) Positive 24 hr ph study
Answers
1. c
Squamocolumnar junction ( Z line) is different from the Gastroesophageal junction. Z line is the junction where the red coarse squamous epithelium merges with the pale glossy columnar epithelium.
The Gastroesopheal junction is identified from (i) proximal rugal folds of stomach (ii) Distal palisading vessels of oesophagus.
If the Z line coincides with the Gastroesophageal junction (GE) junction) this is normal oesophagus.
If Z line is more than 2 cm away from Gastroesophageal junction, that means the apparently the oesophagus is lined by columnar epithelium but this is not diagnostic of Barrett's oesophagus. Only when the biopsy of that area reveals that the epithelium is columnar in nature the diagnosis of barrette's oesophagus is made.
Short segment Barrett's oesophagus is less than 3cm and long segment is more than 3 cm length of intestinal metaplasia.
Schakelford surgery of alimentary canal Volume 6th page 102-103
2. b
In Chromoendoscopy various dyes are used to identify the cells lining the oesophagus. These dyes stain the cells that absorb them or they accumulate in the mucosal crevices to enhance the architectural framework.
Congo red is not used in endoscopy. I t is a dye that was used to test for the completeness of vagotomy.
Potassium Iodide -- absorbed by squamous epithelium and stains it brown. It identifies early neoplasm
Methylene blue absorbed by intestinal type of cells
Cresyl violet stains columnar cells purple
3. d
22-50% of patients with Gastroesophageal disease (GERD) develop complications. The aim of management in these patients is to identify those who require surgery for definitive management
These include
i) Anatomical and physiological markers of severe disease like defective lower oesophageal sphincter, poor peristalsis, large hiatal hernia and bile reflux
ii) Severe erosive esophagitis
iii) Barrett's oesophagus
iv) young age
v) Progressive respiratory symptoms
Hiatus hernia is seen in upto 80% of patients with GERD and mere presence of hernia is no indication for surgery.
4. a
The best response to ANTIREFLUX SURGERY eg Nissen's fundoplication is seen when there is demonstrable acid reflux from the stomach to the oesophagus (most commonly due to deficient lower oesophageal sphincter).
98% response can be seen who have symptomatic relief with PPI s (acid reduction), typical symptoms of GERD such as heartburn, regurgitation and dysphagia and positive 24 hr ph monitoring studies. Patients with atypical GERD symptoms such as asthma, chough, wheeze etc are benefited less after Fundoplication.
