The Specialty certificate in Gastroenterology SCE covers the whole of the curriculum of the specialty training in gastroenterology in the UK. Preparation for this exam requires a wide breadth of knowledge around the curriculum . As knowledge is constantly advancing , awareness of current and updated guidelines is important.This blog is an attempt to pool all resources in one site with regular updates.
Dr Elmuhtady Said
Curriculum for Specialty Certificate Examination in Gastroenterology
A 50-year-old man complains of chest pain and dysphagia. Manometry reveals prolonged, repetitive and high amplitude contractions. The lower oesophageal sphincter pressure is increased and there is incomplete relaxation of the sphincter. What is the most likely diagnosis?
This is most likely to be diffuse oesophageal spasm. The manometry findings are typical. Achalasia typically causes absence of peristalsis in the body of the oesophagus.
In hypertensive lower oesophageal sphincter, the lower oesophageal sphincter pressure is high but oesophageal contractions in the body of the oesophagus are normal.
An 86-year-old woman presents with 2 years of progressive dysphagia, first for solid foods and now for both solids and liquids. She also reports episodes of regurgitation of undigested food and has lost 23 lbs. Her past medical history is significant for occasionally symptomatic coronary artery disease despite previous 2-vessel stenting, hypertension, and cerebrovascular disease. She is maintained on metoprolol, clopidogrel, enalapril, and baby aspirin. On physical examination, she is thin, not in distress, and with normal vital signs. Chest examination reveals end-inspiratory crackles at the right lung base. On endoscopy there is retained fluid in the esophageal body but the endoscope passes through the lower esophageal sphincter without resistance. There are no strictures or masses in the esophagus or the gastric cardia. Esophageal manometry shows esophageal body aperistalsis and incomplete lower esophageal sphincter relaxation upon swallowing. Which of the following is the most appropriate therapy for this patient?
A. Peroral endoscopic myotomy (POEM)
B. Botulinum toxin injection of the lower esophageal sphincter
C. Laparoscopic myotomy
D. Endoscopic pneumatic dilation
correct answer B
Explanation
This patient’s history is typical for esophageal achalasia, with esophageal fluid retention and chronic aspiration to the right lower lung. Endoscopy has excluded the presence of a mass lesion leading to partial esophageal obstruction and esophageal manometry has revealed an elevated lower esophageal sphincter resting pressure, failure of the lower esophageal sphincter to relax with swallowing, and absent esophageal body peristalsis. The two most frequently used treatments for achalasia are pneumatic dilation of the esophagus or surgical myotomy both with approximately 90% success rates at one year. However, endoscopic pneumatic dilation carries a 4% risk of esophageal perforation while surgical myotomy may lead to acid reflux in up to 15% of cases. Botulinum toxin injection of the lower esophageal sphincter inhibits the release of acetylcholine from nerve endings and may provide symptomatic relief in patients like this one who because of age or co-morbidities are not candidates for invasive endoscopic or surgical therapies. In general, endoscopic pneumatic dilation and botulinum toxin injection are similar in improving symptoms over 1-2 years, although most patients treated with botulinum toxin will require additional treatments. Peroral endoscopic myotomy is a new endoscopic procedure during which a submucosal tunnel is made, followed by a myotomy of the inner circular muscle layer, 7 cm in the distal esophagus and 2-5 cm into the cardia. Although symptom reduction or elimination has been reported in most cases, the follow-up has been short (months); its invasive nature would make it unsuitable for this patient.
Which of the following is the most accurate statement regarding transient lower esophageal sphincter relaxation (TLESr)? A. TLESr is a predominant mechanism of gastroesophageal reflux in patients with GERD, but not in those without this condition. B. All TLESr episodes are accompanied by gastroesophageal reflux. C. TLESr episodes are vagally mediated and occur in response to gastric distention. D. TLESr episodes generally occur after swallowing and are usually accompanied by esophageal peristalsis.
A 47-year-old woman with prominent heartburn has been diagnosed with CREST syndrome (limited scleroderma). Esophageal manometry would be expected to show which of the following patterns? A. Reduction in peristaltic contraction amplitude in the distal esophagus along with LES hypotension B. Forceful esophageal contractions with impaired LES relaxation C. Pharyngeal and upper esophageal hypomotility D. LES hypotension with normal esophageal peristalsis
correct answer A Patients with scleroderma have diminished esophageal contractions in the smooth muscle (distal) portion of the esophagus, along with LES hypotension. Similar changes are seen in patients with the generalized and limited (CREST) form of the disease.
I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the liver already present. I started on antiviral medications which reduced the viral load initially. After a couple of years the virus became resistant. I started on HEPATITIS B Herbal treatment from ULTIMATE LIFE CLINIC (www.ultimatelifeclinic.com) in March, 2020. Their treatment totally reversed the virus. I did another blood test after the 6 months long treatment and tested negative to the virus. Amazing treatment! This treatment is a breakthrough for all HBV carriers.
A 50-year-old man complains of chest pain and dysphagia. Manometry reveals prolonged, repetitive and high amplitude contractions. The lower oesophageal sphincter pressure is increased and there is incomplete relaxation of the sphincter.
ReplyDeleteWhat is the most likely diagnosis?
1-Achalasia
2-Barrett's oesophagus
3-Diffuse oesophageal spasm
4-Hypertensive lower oesophageal sphincter
5-Scleroderma
This is most likely to be diffuse oesophageal spasm. The manometry findings are typical. Achalasia typically causes absence of peristalsis in the body of the oesophagus.
In hypertensive lower oesophageal sphincter, the lower oesophageal sphincter pressure is high but oesophageal contractions in the body of the oesophagus are normal.
An 86-year-old woman presents with 2 years of progressive dysphagia, first for solid foods and now for both solids and liquids. She also reports episodes of regurgitation of undigested food and has lost 23 lbs. Her past medical history is significant for occasionally symptomatic coronary artery disease despite previous 2-vessel stenting, hypertension, and cerebrovascular disease. She is maintained on metoprolol, clopidogrel, enalapril, and baby aspirin. On physical examination, she is thin, not in distress, and with normal vital signs. Chest examination reveals end-inspiratory crackles at the right lung base. On endoscopy there is retained fluid in the esophageal body but the endoscope passes through the lower esophageal sphincter without resistance. There are no strictures or masses in the esophagus or the gastric cardia. Esophageal manometry shows esophageal body aperistalsis and incomplete lower esophageal sphincter relaxation upon swallowing. Which of the following is the most appropriate therapy for this patient?
ReplyDeleteA. Peroral endoscopic myotomy (POEM)
B. Botulinum toxin injection of the lower esophageal sphincter
C. Laparoscopic myotomy
D. Endoscopic pneumatic dilation
correct answer B
Explanation
This patient’s history is typical for esophageal achalasia, with esophageal fluid retention and chronic aspiration to the right lower lung. Endoscopy has excluded the presence of a mass lesion leading to partial esophageal obstruction and esophageal manometry has revealed an elevated lower esophageal sphincter resting pressure, failure of the lower esophageal sphincter to relax with swallowing, and absent esophageal body peristalsis. The two most frequently used treatments for achalasia are pneumatic dilation of the esophagus or surgical myotomy both with approximately 90% success rates at one year. However, endoscopic pneumatic dilation carries a 4% risk of esophageal perforation while surgical myotomy may lead to acid reflux in up to 15% of cases. Botulinum toxin injection of the lower esophageal sphincter inhibits the release of acetylcholine from nerve endings and may provide symptomatic relief in patients like this one who because of age or co-morbidities are not candidates for invasive endoscopic or surgical therapies. In general, endoscopic pneumatic dilation and botulinum toxin injection are similar in improving symptoms over 1-2 years, although most patients treated with botulinum toxin will require additional treatments. Peroral endoscopic myotomy is a new endoscopic procedure during which a submucosal tunnel is made, followed by a myotomy of the inner circular muscle layer, 7 cm in the distal esophagus and 2-5 cm into the cardia. Although symptom reduction or elimination has been reported in most cases, the follow-up has been short (months); its invasive nature would make it unsuitable for this patient.
Which of the following is the most accurate statement regarding transient lower esophageal sphincter relaxation (TLESr)?
ReplyDeleteA. TLESr is a predominant mechanism of gastroesophageal reflux in patients with GERD, but not in those without this condition.
B. All TLESr episodes are accompanied by gastroesophageal reflux.
C. TLESr episodes are vagally mediated and occur in response to gastric distention.
D. TLESr episodes generally occur after swallowing and are usually accompanied by esophageal peristalsis.
correct answer C
A 47-year-old woman with prominent heartburn has been diagnosed with CREST syndrome (limited scleroderma). Esophageal manometry would be expected to show which of the following patterns?
ReplyDeleteA. Reduction in peristaltic contraction amplitude in the distal esophagus along with LES hypotension
B. Forceful esophageal contractions with impaired LES relaxation
C. Pharyngeal and upper esophageal hypomotility
D. LES hypotension with normal esophageal peristalsis
correct answer A
Patients with scleroderma have diminished esophageal contractions in the smooth muscle (distal) portion of the esophagus, along with LES hypotension. Similar changes are seen in patients with the generalized and limited (CREST) form of the disease.
I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the
ReplyDeleteliver already present. I started on antiviral medications which
reduced the viral load initially. After a couple of years the virus
became resistant. I started on HEPATITIS B Herbal treatment from
ULTIMATE LIFE CLINIC (www.ultimatelifeclinic.com) in March, 2020. Their
treatment totally reversed the virus. I did another blood test after
the 6 months long treatment and tested negative to the virus. Amazing
treatment! This treatment is a breakthrough for all HBV carriers.