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Question 1: Achalasia

Stem: A 45-year-old woman presents with a 5-year history of dysphagia to both solids and liquids, associated with regurgitation of undigested food. A barium swallow examination is performed. The images demonstrate a massively dilated thoracic oesophagus that is fluid-filled and tapers to a smooth, symmetric, “bird’s beak” narrowing at the gastro-oesophageal junction (GOJ).

Question: What is the most likely diagnosis?

(A) Oesophageal Carcinoma (B) Achalasia (C) Peptic Stricture (D) Scleroderma Oesophagus (E) Oesophageal Web

Correct Answer: (B) Achalasia.

Explanation:

  • Why (B) is correct: This is the classic, textbook presentation of achalasia. It’s a motility disorder where the lower oesophageal sphincter (LES) fails to relax, causing functional obstruction. This leads to progressive dilatation of the oesophageal body and the classic “bird’s beak” sign at the GOJ on a barium swallow. Dysphagia to both solids and liquids is a key clinical clue.
  • Why (A) is wrong: Oesophageal carcinoma would cause an irregular, asymmetric, or “shouldered” stricture, not a smooth, symmetric taper.
  • Why (C) is wrong: A peptic stricture (from chronic reflux) is typically a smooth, short-segment stricture in the distal oesophagus, but it is not associated with massive, aperistaltic dilatation of the entire oesophagus.
  • Why (D) is wrong: Scleroderma also causes a dilated, aperistaltic oesophagus, but the LES is typically patulous (wide open), leading to severe reflux, not obstruction.
  • Why (E) is wrong: An oesophageal web (e.g., Plummer-Vinson) is a thin, shelf-like defect in the proximal oesophagus.

Key Points: Achalasia

  • Pathology: A primary oesophageal motility disorder; failure of LES relaxation and aperistaltis of the oesophageal body.
  • Clinical: Dysphagia to solids and liquids, regurgitation, chest pain.
  • Imaging (Barium Swallow):
    • “Bird’s Beak” Sign: Smooth, tapered narrowing at the GOJ.
    • Dilated, “sigmoid” oesophagus (often fluid/food-filled).
    • Absence of peristalsis.
  • Complication: Increased risk of oesophageal (squamous cell) carcinoma.

Question 2: Oesophageal Carcinoma (Adenocarcinoma)

Stem: A 68-year-old man with a long-standing history of GORD and known Barrett’s oesophagus presents with new-onset, progressive dysphagia to solids. A CT scan of the chest and abdomen is performed. It reveals a focal, irregular, enhancing circumferential wall thickening of the distal oesophagus at the GOJ.

Question: What is the most likely histological type for this malignancy?

(A) Squamous Cell Carcinoma (B) Adenocarcinoma (C) Gastrointestinal Stromal Tumour (GIST) (D) Oesophageal Lymphoma (E) Leiomyoma

Correct Answer: (B) Adenocarcinoma.

Explanation:

  • Why (B) is correct: The key risk factor is Barrett’s oesophagus (columnar metaplasia from chronic reflux). Adenocarcinoma arises from this metaplastic tissue, and therefore its classic location is the distal oesophagus / GOJ.
  • Why (A) is wrong: Squamous Cell Carcinoma (SCC) is the other major type, but its main risk factors are smoking and alcohol. Its classic location is the proximal or mid-oesophagus.
  • Why (C) is wrong: A GIST is a submucosal tumour that typically grows exophytically (outwards) and is hypervascular; it does not typically cause a circumferential, mucosal stricture.
  • Why (D) is wrong: Lymphoma of the oesophagus is rare and usually appears as a bulky, infiltrative mass.
  • Why (E) is wrong: A leiomyoma is a benign submucosal tumour that appears as a smooth, non-invasive mass.

Key Points: Oesophageal Carcinoma

  • Adenocarcinoma:
    • Location: Distal 1/3 / GOJ.
    • Risk Factors: GORD and Barrett’s Oesophagus.
    • Most common type in the UK/USA.
  • Squamous Cell Carcinoma (SCC):
    • Location: Proximal 2/3 (mid or upper).
    • Risk Factors: Smoking and Alcohol.
    • Most common type worldwide.

Question 3: Pharyngeal Pouch (Zenker’s)

Stem: An 80-year-old man presents with a history of dysphagia, regurgitation of food eaten days earlier, and recurrent aspiration pneumonia. A barium swallow study is performed. The lateral view demonstrates a large, posterior outpouching arising from the midline of the posterior hypopharynx, just superior to the cricopharyngeus muscle.

Question: What is the most likely diagnosis?

(A) Zenker’s Diverticulum (B) Killian-Jamieson Diverticulum (C) Traction Diverticulum (D) Laryngocoele (E) Oesophageal Web

Correct Answer: (A) Zenker’s Diverticulum.

Explanation:

  • Why (A) is correct: This is the classic location and presentation. A Zenker’s diverticulum is a false diverticulum (pulsion type) that arises from a posterior area of weakness called Killian’s dehiscence (between the thyropharyngeus and cricopharyngeus muscles). It projects posteriorly and to the left.
  • Why (B) is wrong: A Killian-Jamieson diverticulum is a true diverticulum, is much rarer, and arises anterolaterally from the cervical oesophagus, below the cricopharyngeus.
  • Why (C) is wrong: A traction diverticulum is a true diverticulum (all layers) of the mid-oesophagus, caused by pulling from adjacent old, fibrotic lymph nodes (e.g., from TB).
  • Why (D) is wrong: A laryngocoele is an air-filled dilatation of the laryngeal ventricle, which is an airway structure, not a pharyngeal pouch.
  • Why (E) is wrong: An oesophageal web is a thin, shelf-like defect.

Key Points: Zenker’s Diverticulum

  • Definition: A pulsion (false) diverticulum of the posterior hypopharynx.
  • Location: Arises from the midline Killian’s dehiscence (a posterior weak spot).
  • Clinical: Dysphagia, regurgitation, halitosis, aspiration pneumonia.
  • Imaging: A contrast-filled sac arising from the posterior hypopharynx, best seen on a lateral view.

Question 4: Hiatus Hernia (Rolling)

Stem: A 70-year-old woman has a chest X-ray for a cough, which shows a large, retrocardiac air-fluid level. A subsequent barium meal study demonstrates that the gastro-oesophageal junction (GOJ) is in its normal, sub-diaphragmatic position. However, the gastric fundus has herniated through the phreno-oesophageal membrane and is located alongside the distal oesophagus within the thorax.

Question: What type of hiatus hernia is this?

(A) Type I (Sliding) (B) Type II (Rolling / Para-oesophageal) (C) Type III (Mixed) (D) Type IV (E) Morgagni Hernia

Correct Answer: (B) Type II (Rolling / Para-oesophageal).

Explanation:

  • Why (B) is correct: This is the definition of a Type II, or “rolling,” hernia. The key feature is a normal GOJ position, with the gastric fundus “rolling” up alongside it. This is less common but more dangerous than a sliding hernia, as it can strangulate or volvulise.
  • Why (A) is wrong: A Type I (Sliding) hernia is the most common type (>90%). In this case, the GOJ itself slides up into the thorax.
  • Why (C) is wrong: A Type III (Mixed) hernia has both a sliding component (the GOJ is in the chest) and a rolling component (the fundus is also in the chest).
  • Why (D) is wrong: A Type IV hernia is a large para-oesophageal hernia that also contains other abdominal organs (e.g., colon, spleen).
  • Why (E) is wrong: A Morgagni hernia is an anterior diaphragmatic hernia, not at the oesophageal hiatus.

Key Points: Hiatus Hernia

  • Type I (Sliding): GOJ is above the diaphragm. Very common.
  • Type II (Rolling): GOJ is normal. Fundus herniates alongside. (High risk of strangulation).
  • Type III (Mixed): Both GOJ and fundus are above the diaphragm.
  • Type IV: Contains other organs (spleen, colon, etc.).

Question 5: Gastric Volvulus

Stem: An 85-year-old woman, known to have a large para-oesophageal hernia, presents to the emergency department with acute, severe epigastric pain, retching, and an inability to pass a nasogastric tube. An abdominal X-ray shows a massively distended stomach in the left upper quadrant with a “double bubble” appearance. A CT scan confirms the stomach has rotated on its long axis.

Question: This rotation, where the greater curvature flips superiorly above the lesser curvature, is known as:

(A) Organo-axial volvulus (B) Mesentero-axial volvulus (C) Caecal volvulus (D) Sigmoid volvulus (E) Oesophageal volvulus

Correct Answer: (A) Organo-axial volvulus.

Explanation:

  • Why (A) is correct: An organo-axial volvulus is when the stomach rotates along its long axis (from the GOJ to the pylorus). This is the more common type and is frequently associated with a para-oesophageal hernia. The greater curvature flips superiorly.
  • Why (B) is wrong: A mesentero-axial volvulus is when the stomach rotates along its short axis (from the lesser to the greater curvature). This is less common.
  • Why (C) & (D) are wrong: These refer to volvulus of the large bowel, not the stomach.
  • Why (E) is wrong: Oesophageal volvulus is not a standard medical term; the oesophagus becomes torsed with the stomach.

Key Points: Gastric Volvulus

  • Clinical: Borchardt’s Triad: 1. Severe epigastric pain, 2. Retching without vomiting, 3. Inability to pass an NG tube.
  • Organo-axial (Common): Rotation along the long axis. Associated with para-oesophageal hernias.
  • Mesentero-axial (Rare): Rotation along the short axis.
  • Note: This is a surgical emergency due to the risk of strangulation and perforation.

Question 6: Linitis Plastica

Stem: A 55-year-old man presents with early satiety, weight loss, and dyspepsia. A barium meal is performed, which shows the stomach is non-distensible, diffusely narrowed, and rigid, with effaced mucosal folds.

Question: This “leather bottle” appearance is most characteristic of:

(A) Gastric Adenocarcinoma (Scirrhous type) (B) Gastric Lymphoma (C) Peptic Ulcer Disease (D) Crohn’s Disease (E) Gastric Varices

Correct Answer: (A) Gastric Adenocarcinoma (Scirrhous type).

Explanation:

  • Why (A) is correct: The “leather bottle” stomach, or linitis plastica, is the classic appearance of a scirrhous-type gastric adenocarcinoma. This is an infiltrative malignancy that spreads through the submucosa, causing a desmoplastic (fibrotic) reaction that makes the stomach wall thick, rigid, and non-distensible.
  • Why (B) is wrong: Gastric lymphoma also causes massive wall thickening, but it is typically “softer” and more pliable, dilating the stomach rather than narrowing it.
  • Why (C) is wrong: Peptic ulcers are focal; they do not cause diffuse, rigid narrowing.
  • Why (D) is wrong: Crohn’s disease of the stomach is rare but would cause aphthous ulcers and cobblestoning, not this rigid appearance.
  • Why (E) is wrong: Varices are serpiginous filling defects and do not cause wall rigidity.

Key Points: Linitis Plastica

  • Definition: A “leather bottle” stomach, caused by diffuse infiltration of the gastric wall.
  • Classic Cause: Scirrhous-type (infiltrative) gastric adenocarcinoma.
  • Other Causes: Can be mimicked by gastric lymphoma or, rarely, metastatic breast cancer.
  • Imaging: A rigid, non-distensible, and diffusely narrowed stomach.
  • Prognosis: Extremely poor, as it is usually advanced at diagnosis.

Question 7: Oesophageal Varices

Stem: A 60-year-old man with alcoholic liver cirrhosis presents with haematemesis. An urgent CT angiogram is performed. The images demonstrate multiple, enlarged, serpiginous filling defects within the wall of the distal oesophagus. The portal vein is enlarged, and there is splenomegaly.

Question: What is the most likely diagnosis for the oesophageal finding?

(A) Oesophageal Varices (B) Varicoid Carcinoma (C) Oesophagitis (D) Leiomyoma (E) Oesophageal Duplication Cyst

Correct Answer: (A) Oesophageal Varices.

Explanation:

  • Why (A) is correct: The clinical context (cirrhosis, haematemesis) and imaging findings (signs of portal hypertension, splenomegaly) are key. Oesophageal varices are dilated submucosal veins that form as a porto-systemic collateral. On CT or barium, they appear as longitudinal, serpiginous (snake-like) filling defects in the distal oesophagus.
  • Why (B) is wrong: Varicoid carcinoma is a rare form of SCC that mimics varices, but true varices are far more likely in a patient with known cirrhosis.
  • Why (C) is wrong: Oesophagitis would show diffuse wall thickening or ulceration, not serpiginous filling defects.
  • Why (D) is wrong: A leiomyoma is a solitary, smooth, submucosal mass.
  • Why (E) is wrong: This is a simple cystic structure.

Key Points: Oesophageal Varices

  • Definition: Dilated submucosal veins in the distal oesophagus.
  • Cause: Portal hypertension (most commonly from cirrhosis). They are a collateral pathway (portal vein -> left gastric vein -> oesophageal plexus -> azygos vein -> SVC).
  • Imaging:
    • Barium: Serpiginous, “worm-like” filling defects.
    • CECT: Avidly enhancing serpiginous structures in the oesophageal wall.
  • Risk: High risk of life-threatening rupture and haematemesis.

Question 8: GIST

Stem: A 70-year-old woman has an incidental finding on an abdominal CT. There is a 6 cm, well-defined mass arising from the wall of the gastric fundus. The mass is hypervascular (enhances avidly), grows exophytically (outwards), and has a small central area of low-density (necrosis).

Question: What is the most likely diagnosis?

(A) Gastric Adenocarcinoma (B) Gastrointestinal Stromal Tumour (GIST) (C) Leiomyoma (D) Gastric Lymphoma (E) Splenic Artery Aneurysm

Correct Answer: (B) Gastrointestinal Stromal Tumour (GIST).

Explanation:

  • Why (B) is correct: This is the classic appearance. GISTs are the most common mesenchymal tumour of the GI tract. They typically present as large, hypervascular, exophytic masses. The stomach is the most common location. They often outgrow their blood supply, leading to central necrosis, ulceration, or haemorrhage.
  • Why (A) is wrong: Adenocarcinoma is a mucosal, infiltrative lesion that causes wall thickening and luminal narrowing.
  • Why (C) is wrong: A leiomyoma is also a submucosal mass but is typically hypovascular, small, and benign. A large, enhancing mass is a GIST until proven otherwise.
  • Why (D) is wrong: Lymphoma is typically a hypovascular, infiltrative, bulky mass that causes wall thickening.
  • Why (E) is wrong: A splenic artery aneurysm would be adjacent to, but not arising from, the gastric wall, and would fill with contrast identical to the aorta.

Key Points: Gastrointestinal Stromal Tumour (GIST)

  • Pathology: Mesenchymal tumour arising from the interstitial cells of Cajal (CD117/c-kit positive).
  • Location: Stomach (most common), followed by small bowel.
  • Imaging:
    • Hypervascular (avidly enhancing).
    • Exophytic (outward) growth pattern.
    • Often large, with central necrosis, ulceration, or haemorrhage.

Question 9: Oesophageal Rupture (Boerhaave’s)

Stem: A 48-year-old man presents with severe, acute retrosternal chest pain and vomiting after a bout of binge drinking. A CT chest shows a full-thickness defect in the posterolateral wall of the left distal oesophagus, with associated mediastinal air, a left-sided hydropneumothorax, and pleural fluid.

Question: What is the most likely diagnosis?

(A) Boerhaave Syndrome (B) Mallory-Weiss Tear (C) Oesophageal Carcinoma (D) Oesophageal Ulcer (E) Hiatus Hernia Strangulation

Correct Answer: (A) Boerhaave Syndrome.

Explanation:

  • Why (A) is correct: Boerhaave syndrome is the spontaneous, full-thickness rupture of the oesophagus from a sudden rise in intra-oesophageal pressure (e.g., forceful vomiting). The classic location is the posterolateral left distal oesophagus. The key findings are mediastinal air (pneumomediastinum) and hydropneumothorax.
  • Why (B) is wrong: A Mallory-Weiss tear is a partial-thickness mucosal tear at the GOJ, also from vomiting. It causes haematemesis but does not perforate, so there is no mediastinal air.
  • Why (C) & (D) are wrong: Carcinoma and ulcers can perforate, but this is a chronic process, not an acute event after vomiting.
  • Why (E) is wrong: A strangulated hernia would show a non-enhancing, fluid-filled stomach in the chest, not a primary oesophageal perforation.

Key Points: Boerhaave Syndrome

  • Definition: Spontaneous, full-thickness oesophageal perforation.
  • Mechanism: Forceful vomiting against a closed cricopharyngeus.
  • Classic Location: Posterolateral aspect of the left distal oesophagus (a weak point).
  • Imaging: Pneumomediastinum (mediastinal air) is the key finding. Also, pneumothorax, pleural effusion (hydropneumothorax), and oesophageal wall defect.

Question 10: Benign Gastric Ulcer

Stem: A 50-year-old man with dyspepsia undergoes a barium meal. A 1 cm ulcer crater is seen along the lesser curvature of the stomach. The ulcer is well-defined and projects beyond the normal gastric contour. The mucosal folds are seen to radiate smoothly to the very edge of the ulcer.

Question: These features are most characteristic of:

(A) A benign gastric ulcer. (B) A malignant gastric ulcer. (C) A GIST. (D) A leiomyoma. (E) Gastric varices.

Correct Answer: (A) A benign gastric ulcer.

Explanation:

  • Why (A) is correct: These are the two classic signs of a benign ulcer. 1) It projects beyond the contour of the gastric wall (as it is a “hole”). 2) The surrounding mucosal folds are smooth and radiate all the way to the ulcer margin.
  • Why (B) is wrong: A malignant ulcer (an ulcerated carcinoma) is typically a mass that has ulcerated. Therefore, it is seen as a filling defect within the gastric contour. The folds are nodular, irregular, and stop short of the ulcer crater (“Hampton’s line,” “Carman’s meniscus sign”).
  • Why (C) & (D) are wrong: These are submucosal tumours and would appear as smooth filling defects, not ulcers.
  • Why (E) is wrong: These are serpiginous filling defects.

Key Points: Benign vs. Malignant Gastric Ulcer (Barium)

  • Benign Ulcer:
    • Projects beyond the gastric contour.
    • Folds radiate to the ulcer margin.
    • Smooth, well-defined crater.
  • Malignant Ulcer:
    • Mass within the gastric contour (Carman’s meniscus sign).
    • Folds stop short of the ulcer crater (due to the surrounding malignant mass).
    • Irregular, nodular, heaped-up margins.

Question 11: Oesophageal Atresia (Type C)

Stem: A newborn infant presents with excessive drooling, choking, and respiratory distress. An attempt to pass a nasogastric (NG) tube is unsuccessful, as the tube coils in the upper chest. An X-ray shows the coiled tube in a blind-ending proximal oesophageal pouch and, notably, air within the stomach and small bowel.

Question: This combination of findings is diagnostic of which type of tracheo-oesophageal fistula (TEF)?

(A) Type C (Proximal atresia with distal fistula) (B) Type A (Isolated oesophageal atresia) (C) Type E (H-type fistula) (D) Oesophageal web (E) Pyloric stenosis

Correct Answer: (A) Type C (Proximal atresia with distal fistula).

Explanation:

  • Why (A) is correct: This is the most common type (>85%). The coiled NG tube confirms the proximal oesophageal atresia (blind pouch). The presence of gas in the stomach proves that there must be a connection between the trachea and the distal oesophagus (the TEF).
  • Why (B) is wrong: Type A (isolated atresia with no fistula) would also have a coiled NG tube, but the abdomen would be “gasless” as no air can reach the stomach.
  • Why (C) is wrong: An H-type fistula (Type E) is an isolated connection without atresia. The NG tube would pass normally into the stomach, but the patient would have aspiration.
  • Why (D) is wrong: An oesophageal web would cause obstruction but not a coiled pouch in this manner.
  • Why (E) is wrong: Pyloric stenosis presents at 2-8 weeks with projectile vomiting and would have a normal oesophagus.

Key Points: Oesophageal Atresia / TEF (Gross Classification)

  • Type C (Most Common, 85%):Proximal atresia + Distal TEF.
    • X-ray: Coiled NG tube + Gas in stomach.
  • Type A (Second Most Common, 10%):Isolated atresia (no fistula).
    • X-ray: Coiled NG tube + Gasless abdomen.

Question 12: Gastric Lymphoma

Stem: A 62-year-old man presents with non-specific abdominal pain and weight loss. A CT scan of the abdomen shows massive, circumferential, homogeneous thickening of the wall of the gastric body and antrum. The gastric lumen itself is not narrowed and may even be slightly dilated, despite a wall thickness of 4 cm.

Question: This appearance of massive, bulky thickening without significant luminal obstruction is most suggestive of:

(A) Gastric Lymphoma (MALToma) (B) Gastric Adenocarcinoma (Linitis Plastica) (C) GIST (D) Crohn’s Disease (E) Ménétrier’s Disease

Correct Answer: (A) Gastric Lymphoma (MALToma).

Explanation:

  • Why (A) is correct: This is a key differentiating feature. Lymphoma is an infiltrative tumour that often spreads in the submucosa. Unlike adenocarcinoma, it is “softer” and does not elicit a fibrotic reaction, so it can cause massive, bulky wall thickening without causing obstruction.
  • Why (B) is wrong: Linitis plastica (adenocarcinoma) also causes diffuse thickening, but it is fibrotic (scirrhous) and classically causes rigid narrowing and obstruction.
  • Why (C) is wrong: A GIST is an exophytic, focal, hypervascular mass, not a circumferential, infiltrative process.
  • Why (D) is wrong: Crohn’s disease of the stomach is rare and causes aphthous ulcers and cobblestoning, not massive thickening.
  • Why (E) is wrong: Ménétrier’s disease is a rare cause of massive, thickened gastric folds (rugae), but it is a benign, protein-losing gastropathy, not a malignant tumour.

Key Points: Gastric Lymphoma

  • Definition: Most common is non-Hodgkin’s (MALToma) associated with H. pylori.
  • Location: Stomach is the most common site for GI lymphoma.
  • Imaging:
    • Massive, bulky, homogeneous wall thickening.
    • No/Minimal Obstruction: The lumen is often preserved or even dilated.
    • Typically hypovascular (unlike GIST).

Question 13: Corrosive Oesophagitis

Stem: A 30-year-old man presents to the ED after ingesting a large amount of alkali (caustic soda). A CT scan is performed.

Question: What is the most feared, acute complication that the radiologist must look for?

(A) Transmural necrosis and perforation. (B) Development of a peptic stricture. (C) Development of Barrett’s oesophagus. (D) Development of a traction diverticulum. (E) Oesophageal varices.

Correct Answer: (A) Transmural necrosis and perforation.

Explanation:

  • Why (A) is correct: In the acute phase (first hours to days) of a severe corrosive injury, the primary concern is transmural necrosis (liquefaction necrosis from alkali; coagulation from acid), which leads to perforation, mediastinitis, and death. The CT scan is used to look for wall defects, pneumomediastinum, and abscesses.
  • Why (B) is wrong: Stricture formation is the most common chronic or late complication, occurring weeks to months after the initial injury.
  • Why (C) is wrong: Barrett’s is caused by chronic acid reflux, not an acute corrosive ingestion.
  • Why (D) & (E) are wrong: These are unrelated pathologies.

Key Points: Corrosive Oesophagitis

  • Cause: Ingestion of strong alkali (e.g., lye) or acid.
  • Alkali: Liquefaction necrosis. Causes deeper injury, more common in the oesophagus.
  • Acid: Coagulation necrosis. Often injures the stomach more (pyloric spasm).
  • Acute Complication (Days): Perforation, mediastinitis, peritonitis.
  • Chronic Complication (Weeks/Months): Stricture formation.
  • Late Complication (Years): Increased risk of Squamous Cell Carcinoma.

Question 14: Scleroderma Oesophagus

Stem: A 55-year-old woman with CREST syndrome presents with severe heartburn. A barium swallow reveals a dilated, aperistaltic oesophagus in its distal two-thirds. At the GOJ, the sphincter is wide open (patulous), allowing free reflux of barium from the stomach.

Question: What is the most likely diagnosis?

(A) Scleroderma Oesophagus (B) Achalasia (C) Chagas Disease (D) Oesophageal Carcinoma (E) Peptic Stricture

Correct Answer: (A) Scleroderma Oesophagus.

Explanation:

  • Why (A) is correct: This is the classic appearance of scleroderma, which is a connective tissue disease that causes atrophy and fibrosis of the smooth muscle. This affects the distal two-thirds of the oesophagus (which is smooth muscle), leading to aperistalsis and dilatation. Crucially, it also destroys the LES, leaving it patulous and wide open, causing severe GORD.
  • Why (B) is wrong: Achalasia is the opposite. It also causes a dilated, aperistaltic oesophagus, but the LES is tightly closed (“bird’s beak”).
  • Why (C) is wrong: Chagas disease (from Trypanosoma cruzi) mimics achalasia, causing mega-oesophagus from destruction of the nerve plexus, leading to a closed LES.
  • Why (D) & (E) are wrong: These would cause narrowing (stenosis), not a wide-open sphincter.

Key Points: Scleroderma Oesophagus

  • Pathology: Atrophy and fibrosis of the smooth muscle.
  • Location: Affects the distal 2/3 of the oesophagus (smooth muscle) and the LES.
  • Imaging:
    • Dilated, aperistaltic oesophagus.
    • Patulous (wide-open) GOJ causing free reflux.
    • Can lead to severe reflux oesophagitis and peptic strictures.
  • Association: Often seen in CREST syndrome (Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly, Telangiectasia).

Question 15: Benign Oesophageal Stricture

Stem: A 60-year-old man with a long history of untreated acid reflux presents with progressive dysphagia to solids. A barium swallow shows a short-segment, smooth, tapered narrowing in the distal oesophagus, just above the GOJ. No associated mass or ulceration is seen.

Question: What is the most likely diagnosis?

(A) Peptic Stricture (B) Adenocarcinoma (C) Squamous Cell Carcinoma (D) Oesophageal Web (E) Oesophageal Varices

Correct Answer: (A) Peptic Stricture.

Explanation:

  • Why (A) is correct: This is the classic appearance of a benign peptic stricture. The long-standing acid reflux (GORD) causes inflammation and eventual fibrosis. This results in a smooth, tapered, short-segment narrowing in the distal oesophagus.
  • Why (B) & (C) are wrong: Malignant strictures (adenocarcinoma or SCC) are typically irregular, nodular, eccentric, and have “shouldered” margins. A short, smooth, tapered narrowing is benign.
  • Why (D) is wrong: An oesophageal web is a very thin, shelf-like defect in the proximal oesophagus.
  • Why (E) is wrong: Varices are serpiginous filling defects and do not cause a fixed stricture.

Key Points: Peptic Stricture

  • Cause: The end-result of chronic, severe GORD (reflux oesophagitis).
  • Location: Distal oesophagus or GOJ.
  • Imaging (Barium):
    • Smooth, symmetric, tapered narrowing.
    • Often short-segment.
    • No associated mass or nodularity.
  • Association: Often seen in conjunction with a sliding hiatus hernia.

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