MCQs on Upper GI Tract

Written by Dr. Andrew McAllister
(MBBS, FRACS) – Surgeon

Question 1

Alfred is a 40-year-old patient in your clinic, who has presented with heartburn and chest pain of 12 months’ duration. The chest pain is unrelated to physical activity, but both the heartburn and chest pain are worse with meals. He started developing difficulty swallowing both liquids and solids and has lost 3 kg in this period. He also has regurgitation, especially when he lies down, which he finds the most disturbing of his problems. He also mentions that rolling back his shoulders or raising his arms eases swallowing for him. Physical examination is unremarkable.
Which one of the following could be the most likely diagnosis?

A) Esophageal cancer
B) Esophageal strictures
C) Scleroderma
D) Esophagitis
E) Achalasia

Correct Answer: E) Achalasia.

Explanation:
This is a classic presentation of achalasia, a primary esophageal motility disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and absence of peristalsis in the esophageal body.

Symptoms include dysphagia to both solids and liquids, regurgitation, substernal chest pain, weight loss, and heartburn. Regurgitation is often the most distressing symptom. Patients sometimes adopt compensatory maneuvers like arching the back or raising the arms to help facilitate swallowing.

Diagnosis can be delayed because early symptoms can mimic gastroesophageal reflux disease (GERD). However, regurgitation unresponsive to PPI therapy, along with dysphagia to both solids and liquids, is a strong clue.

Option A (Esophageal cancer): Less likely in a young patient without risk factors. Cancer typically causes rapid-onset dysphagia with more pronounced weight loss.
Option B (Esophageal strictures): Usually causes dysphagia to solids first, with progression to liquids much later.
Option C (Scleroderma): Involves the esophagus but would usually present with other features like skin thickening or Raynaud’s phenomenon.
Option D (Esophagitis): Typically presents with odynophagia (pain on swallowing) rather than progressive dysphagia.

Question 2

A 57-year-old man presents to your GP clinic with complaints of dysphagia and hoarseness. The first symptom was hoarseness, which started almost one month ago, followed by development of dysphagia after 2 weeks. His past medical history is significant for surgery for achalasia 10 years ago. On examination, normal-appearing but paralyzed vocal cords are noted. A CT scan is arranged that shows a mass in the thoracic inlet.
Which one of the following could be the most likely diagnosis?

A) Stricture formation due to the previous surgery
B) Thyroid cancer
C) Esophageal cancer
D) Laryngeal cancer
E) Lung cancer

Correct Answer: C) Esophageal cancer.

Explanation:
This patient presents with hoarseness followed by dysphagia, and a mass in the thoracic inlet. He also has a history of achalasia, which is a well-established risk factor for esophageal squamous cell carcinoma, especially after a latency period of several years.

In esophageal cancer, hoarseness results from recurrent laryngeal nerve involvement, indicating locally advanced disease. Dysphagia typically begins with solids and progresses to liquids, and occurs when the tumor narrows the esophageal lumen to <13 mm.

Option A (Stricture formation): May occur post-achalasia surgery and explain dysphagia, but does not account for vocal cord paralysis/hoarseness.
Option B (Thyroid cancer): Can invade the recurrent laryngeal nerve, but typically presents as a palpable thyroid nodule. A mass in the thoracic inlet is less likely to be thyroid in origin without a visible neck mass.
Option D (Laryngeal cancer): Causes hoarseness, but not typically dysphagia, unless very advanced. Imaging would usually show a neck mass, not a thoracic one.
Option E (Lung cancer): Especially apical tumors (Pancoast tumors) can cause hoarseness and thoracic inlet masses, but dysphagia is rare unless the esophagus is compressed or invaded—much less common than in esophageal cancer.

Thus, in this context, esophageal cancer is the most likely diagnosis.

Question 3

A 45-year-old patient presents to your GP clinic with complaint of dyspepsia. Evaluations reveal peptic ulcer disease and Helicobacter pylori infection. You start him on a 14-day course of triple therapy with amoxicillin, metronidazole, and pantoprazole. Ten days after completion of treatment, the patient is only partially improved and the dyspepsia still exists to a lesser extent. A urea breath test is performed and turns out positive.

Which one of the following could be the most likely cause of treatment failure in this patient?

A) Amoxicillin resistance
B) Metronidazole resistance
C) Inappropriate timing of the test after treatment
D) Unreliable urea breath test
E) Patient’s non-compliance to treatment

Correct Answer: B) Metronidazole resistance

The most common cause of H. pylori treatment failure is antibiotic resistance, especially to metronidazole and clarithromycin. Among these, metronidazole resistance is more prevalent globally and is a well-recognized cause of treatment failure, particularly in regimens that do not include clarithromycin.

Option A (Amoxicillin resistance): Resistance to amoxicillin is extremely rare, and H. pylori remains highly sensitive to it in most cases.
Option C (Inappropriate timing): Urea breath test should be done at least 4 weeks after completion of antibiotics and 2 weeks after stopping PPIs. In this case, it was done around 10 days after finishing therapy (i.e., 24 days after starting), which is just at the borderline but still less likely to be the main issue compared to drug resistance.
Option D (Unreliable test): Urea breath test is highly sensitive and specific when properly timed and performed using standard methods.
Option E (Non-compliance): There’s no history to suggest poor compliance, and the partial improvement implies the treatment was likely taken as prescribed.

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8. General Surgery Module

8.1 Acute Abdomen

8.2 Upper GI Tract

8.3 Hepatobiliary System

8.4 Lower GI Tract

8.5 Lumps

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