Practice questions Esophageal pathology

Practice questions

Esophageal pathology

Updated: 02/28/2019

© Jun Wang, MD, PhD

1. Use this case for the next two questions. A 35-year-old woman presents with intermittent dysphagia and chest pain for 1 year. The pain is triggered by swallowing large amount of water. It is a sharp pain in the lower substernal area. She denies other symptoms. She has a history of type 2 diabetes but denies any cardiovascular system disorders. She does not smoke cigarette nor drink alcohol. Physical examination reveals no significant abnormalities. Laboratory tests are within normal range. Upper endoscopic exam, 24 hour esophageal impedance-pH monitoring and barium esophagogram reveal no esophageal or stomach abnormalities. What test is appropriate next?

A. Coronary angiogram

B. EKG

C. Esophageal biopsy

D. High-resolution manometry

E. Sonographic exam for mediastinal abnormalities

2. A 35-year-old woman presents with intermittent dysphagia and chest pain for 1 year. The pain is triggered by swallowing large amount of water. It is a sharp pain in the lower substernal area. She denies other symptoms. She has a history of type 2 diabetes but denies any cardiovascular system disorders. She does not smoke cigarette nor drink alcohol. Physical examination reveals no significant abnormalities. Laboratory tests are within normal range. Upper endoscopic exam, 24 hour esophageal impedance-pH monitoring and barium esophagogram reveal no esophageal or stomach abnormalities.

High-resolution manometry reveals simultaneously increased intraesophageal pressure of the entire distal esophagus, following swallowing large amount of water. What is the diagnosis?

A. Achalasia

B. Candidiasis

C. Diffuse esophageal spasm

D. Esophageal web

E. Reflux esophagitis

3. Use this case for the next two questions. A 65-year-old man presents with dysphagia and regurgitation for 3 years. His past medical history is unremarkable. Physical examination and laboratory tests are unremarkable. Upper endoscopic examination reveals dilated distal third esophagus and a stricture near gastro-esophageal junction. No significant mucosal abnormalities are noted. Barium esophagogram reveals dilatation of mid to distal esophagus and a stenosis at gastroesophageal junction. What is most likely the diagnosis?

A. Achalasia

B. Barret esophagus

C. Diffuse esophageal spasm

D. Esophageal web

E. Reflux esophagitis

4. A 65-year-old man presents with dysphagia and regurgitation for 3 years. His past medical history is unremarkable. Physical examination and laboratory tests are unremarkable. Upper endoscopic examination reveals dilated distal third esophagus and a stricture near gastro-esophageal junction. No significant mucosal abnormalities are noted. Barium esophagogram reveals dilatation of mid to distal esophagus and a stenosis at gastroesophageal junction. What is most likely causing his presentations?

A. Distal esophagus scarring

B. Esophageal glandular proliferation

C. Esophageal mucosal protrusions

D. Muscularis propria hypertrophy

E. Squamous cell proliferation

5. A 44-year-old man presents with intermittent dysphagia for 3 months. He denies abdominal pain and other constitutional symptoms. His past medical history and physical examination are unremarkable. Laboratory tests reveals a hemoglobin of 9.5 g/dl (normal 13.5-17.5 g/dl), MCV 72 fL (normal 80-95 fL) and serum iron of 35 microgram/dl (normal 50-150 microgram/dl). The white cells and platelets are unremarkable. Barium esophagogram reveals an irregular filling defect at distal esophagus. Upper endoscopic examination reveals a constricting concentric thickening of esophageal wall with focal mucosal ulceration. Biopsy reveals squamous mucosa with reactive changes. What is the diagnosis?

A. Achalasia

B. Adenocarcinoma

C. Esophagus ring

D. Esophagus web

E. Squamous cell carcinoma

6. A 75-year-old woman presents with vomiting followed by epigastric pain, hematemesis and syncope. She has history of type 2 diabetes and deep vein thrombosis and is current taking Coumadin. Physical examination reveals pale skin with a blood pressure of 85/50 mmHg and heart rate of 110 bpm. Laboratory tests reveals a hemoglobin of 7.4 g/dl (normal 12-16 g/dl), INR of 2.5 (target range: 2-3). All three lineages are morphologically unremarkable. Upper endoscopy reveals a longitudinal fissure along the gastroesophageal junction. What is the diagnosis?

A. Barrett esophagus

B. Candidiasis

C. Mallory Weiss tear

D. Reflux esophagitis and ulcer

E. Varices

7. Use this image for this question. A 55-year-old woman presents with hematemesis for 1 hour. She has a history of alcoholic cirrhosis, type 2 diabetes, and Barrett esophagus. Physical examination reveals pale skin, with a blood pressure of 82/45 mmHg and a heart rate of 130 bpm. Laboratory tests reveal a hemoglobin of 7.5 g/dl (normal 12-16 g/dl), AST of 51U/L (normal 10-34 U/L). His renal function tests, white cells and platelets are within normal range. Upper endoscope examination reveals findings as shown in the image.  What is the diagnosis?

(Image credit: Samir)

A. Adenocarcinoma

B. Candidiasis

C. Esophageal web

D. Mallory Weiss tear

E. Varices

8. Use this image for this question A 31-year-old man presents with dysphagia, odynophagia and retrosternal chest pain for a day. The pain is triggered by any type of food intake. His past medical history is unremarkable. She denies any constitutional symptoms. Physical examination and laboratory tests are unremarkable. Upper endoscopic exam reveal multiple shallow ulcers in a background erythematous mucosa, at distal esophagus. No discrete mass is seen. Cytological examination of these ulcers reveal findings shown in the image. What is the diagnosis?

(Image credit CDC/ Dr. Edwin P. Ewing, Jr. )

A. Adenocarcinoma

B. Candidiasis

C. Eosinophilic esophagitis

D. Herpes esophagitis

E. Squamous cell carcinoma

9. A 49-year-old woman presents with progressive dysphagia and odynophagia for 3 months. She has type 2 diabetes. She has a 30 pack-year history of cigarette smoking and is a social drinker. Physical examination and laboratory tests are unremarkable. Upper endoscopic examination reveals irregular pale to white plaques at distal esophagus. Small ulceration is seen. Biopsy of these lesions reveal hyperplastic squamous epithelium with neutrophilic infiltration. No viral inclusion is seen. Special stain reveal fungal hyphae within the epithelium. What is the diagnosis?

A. Adenocarcinoma

B. Candidiasis

C. Eosinophilic esophagitis

D. Herpes esophagitis

E. Squamous cell carcinoma

10. Use this case for the next two questions. A 24-year-old man presents with dysphagia, nausea and substernal pain for 3 days. He denies other symptoms. He has history of atopic dermatitis before age of 2. He does not smoke cigarette nor drink alcohol. Physical examination and laboratory tests are within normal range. Upper endoscopy reveals white plaques at distal esophagus. Biopsy reveals squamous mucosa with mild squamous hyperplasia and numerous intraepithelial eosinophils. No cytological atypia is seen. Special stain reveals no fungal hyphae. What is the diagnosis?

A. Adenocarcinoma

B. Candidiasis

C. Eosinophilic esophagitis

D. Herpes esophagitis

E. Squamous cell carcinoma

11. A 24-year-old man presents with dysphagia, nausea and substernal pain for 3 days. He denies other symptoms. He has history of atopic dermatitis before age of 2. He does not smoke cigarette nor drink alcohol. Physical examination and laboratory tests are within normal range. Upper endoscopy reveals white plaques at distal esophagus. Biopsy reveals squamous mucosa with mild squamous hyperplasia and numerous intraepithelial eosinophils. No cytological atypia is seen. Special stain reveals no fungal hyphae. What is causing these findings?

A. Allergic reaction

B. Bacterial infection

C. Herpes infection

D. Monoclonal eosinophilic proliferation

E. Parasite infection

12. A 49-year-old man presents with intermittent dysphagia, heartburn and vomiting for 6 months. He drinks a bottle of whiskey a day for 20 years, and has a 30 pack year history of cigarette smoking. Physical examination is unremarkable. Laboratory tests reveals normal CBC and mildly elevated AST. Upper endoscopy examination reveals irregular white patches at distal esophagus. Biopsy of these patches reveals slightly hyperplastic squamous epithelium with diffuse eosinophilic infiltrate. No glandular components are seen. Ambulatory pH monitoring reveals periodically reduced pH, that is compatible with his symptoms. What is likely causing his clinical presentations?

A. Allergic reaction

B. Candida infection

C. Gastric and intestinal metaplasia of distal squamous mucosa

D. Reflux of gastric contents

E. Squamous cell carcinoma

13. Use this case for the next two questions. A 51-year-old man presents with worsening dysphagia and heartburn for 1 week. He has a history of reflux esophagitis for 10 years, and type 2 diabetes for 5 years. Physical examination and laboratory tests are within normal ranges. Gastroscopic examination reveals a few irregular erythematous patches at distal esophagus. No discrete tumor or ulcer is seen. Biopsy reveal mixed squamous and gastric mucosa with mild lymphoplasmacytic infiltrate. Focally there are slightly large cells with pale to gray cytoplasm and small basally located nuclei. Most of the glandular cells have pale pink cytoplasms. No significant architectural or cytological atypia is noted. What is the diagnosis?

A. Adenocarcinoma

B. Barrett esophagus

C. Candidiasis

D. Lymphocytic esophagitis

E. Squamous cell carcinoma

14. A 51-year-old man presents with worsening dysphagia and heartburn for 1 week. He has a history of reflux esophagitis for 10 years, and type 2 diabetes for 5 years. Physical examination and laboratory tests are within normal ranges. Gastroscopic examination reveals a few irregular erythematous patches at distal esophagus. No discrete tumor or ulcer is seen. Biopsy reveal mixed squamous and gastric mucosa with mild lymphoplasmacytic infiltrate. Focally there are slightly large cells with pale to gray cytoplasm and small basally located nuclei. Most of the glandular cells have pale pink cytoplasms. No significant architectural or cytological atypia is noted. What risk is elevated for this patient?

A. Achalasia

B. Adenocarcinoma

C. Esophageal web

D. Massive hemorrhage

E. Metastasis

15. Use this case for the next two questions. A 55-year-old man presents with progressive dysphagia, vomiting and a 20 pound weight loss from 2 months. He has a history of diabetes, helicobacter gastritis, reflux esophagitis, Barrett esophagus, and low grade prostate adenocarcinoma treated with surgery. He smokes cigarette one and a half pack a day for 30 years and is a social drinker. Physical examination is unremarkable. Laboratory tests reveal a hemoglobin of 8 g/dl (normal 13.5-17.5 g/dl). No other abnormality is noted. Barium esophagogram reveals irregular filling defects at distal esophagus. Endoscopy examination reveals irregularly raised area with whitish surface occupying approximately 60% of the circumferences. Biopsy of these lesions reveal mixed squamous and gastric type mucosa. Slightly enlarged columnar cells with greyish cytoplasm and basally located small nuclei are seen. Focally there are irregular glands lined by moderately atypical cells in the lamina propria. The squamous epithelium has scattered neutrophilic and eosinophilic infiltrate. No significant keratinocytic atypia is noted. What is most likely the diagnosis?

A. Adenocarcinoma

B. Candida esophagitis

C. Esophageal web

D. Metastatic prostate adenocarcinoma

E. Squamous cell carcinoma

16. A 55-year-old man presents with progressive dysphagia, vomiting and a 20 pound weight loss from 2 months. He has a history of diabetes, helicobacter gastritis, reflux esophagitis, Barrett esophagus, and low grade prostate adenocarcinoma treated with surgery. He smokes cigarette one and a half pack a day for 30 years and is a social drinker. Physical examination is unremarkable. Laboratory tests reveal a hemoglobin of 8 g/dl (normal 13.5-17.5 g/dl). No other abnormality is noted. Barium esophagogram reveals irregular filling defects at distal esophagus. Endoscopy examination reveals irregularly raised area with whitish surface occupying approximately 60% of the circumferences. Biopsy of these lesions reveal mixed squamous and gastric type mucosa. Slightly enlarged columnar cells with greyish cytoplasm and basally located small nuclei are seen. Focally there are irregular glands lined by moderately atypical cells in the lamina propria. The squamous epithelium has scattered neutrophilic and eosinophilic infiltrate. No significant keratinocytic atypia is noted. What in his history is most likely associated with his current findings?

A. Barrett esophagus

B. Cigarette smoking

C. Diabetes

D. Helicobacter gastritis

E. Prostate adenocarcinoma

17. Use this case for the next two questions. A 79-year-old man presents with progressive dysphagia and a 10 pound weight loss in a month. His medical history including esophagus web, Barrett esophagus, type 2 diabetes and hypertension. He has a 50 pack year history of cigarette smoking and has been drinking wines 2-3 glasses per day for 40 years. Physical examination and laboratory tests are unremarkable. Barium esophagogram reveal irregular filling defect at the mid portion of his esophagus. Upper endoscopy examination reveals a 4.4 cm wide based lesion with surface ulceration. Biopsy reveals irregular nest of cells as shown in the image. What is the diagnosis?

(Image source: The Armed Forces Institute of Pathology (AFIP))

A. Adenocarcinoma

B. Candida esophagitis

C. Eosinophilic esophagitis

D. Esophageal web

E. Squamous cell carcinoma

18. A 79-year-old man presents with progressive dysphagia and a 10 pound weight loss in a month. His medical history including esophagus web, Barrett esophagus, type 2 diabetes and hypertension. He has a 50 pack year history of cigarette smoking and has been drinking wines 2-3 glasses per day for 40 years. Physical examination and laboratory tests are unremarkable. Barium esophagogram reveal irregular filling defect at the mid portion of his esophagus. Upper endoscopy examination reveals a 4.4 cm wide based lesion with surface ulceration. Biopsy reveals irregular nest of cells as shown in the image. What in his history is most likely associated with these findings?

(Image source: The Armed Forces Institute of Pathology (AFIP))

A. Barrett esophagus

B. Cigarette smoking

C. Diabetes

D. Esophagus web

E. Hypertension

Answers

Back to esophagus pathology

Back to contents