USMLE Step 1 Question 390

Question:

A 33-year-old man is seen by his gastroenterologist for progressive dysphagia over the last 3 weeks. Barium swallow shows a dilated esophagus with an area of distal stenosis, resembling a ‘bird beak’ appearance. The treatment of this condition places the patient at a higher risk for which of the following?

Correct Answer: A.  Barrett’s esophagus

This patient presents with achalasia, which results from failure of relaxation of lower esophageal sphincter (LES) due to loss of the myenteric (Auerbach’s) plexus.

The progressive dysphagia is caused by the stenotic LES. Treatment of achalasia includes pneumatic dilation of the LES and surgical myotomy. Because the treatment involves relaxing the LES, the patient can be more prone to acid reflux, which can lead to Barett’s esophagus (A).

Esophageal carcinoma (B) can cause achalasia, but there is no conclusive evidence that achalasia is a premalignant lesion for esophagus cancer. In addition, the choice states squamous cell carcinoma, which tends to occur in the upper 2/3 of the esophagus and is not usually located near LES. Barrett’s esophagus, however, can eventually lead to adenocarcinoma of the esophagus.

Gastric carcinoma (C) may result from disruption of the gastric mucosa from chronic gastritis. Treatment of achalasia doesn’t influence such processes.

Treatment of achalasia doesn’t increase the risk for vomiting or retching which would cause a tear at the gastroesophageal junction (Mallory-Weiss (D). Plummer-Vinson syndrome (E) is a long-term iron deficiency anemia resulting from esophageal webs in the proximal esophagus (near the upper esophageal sphincter). Achalasia is not associated with PVS.