Disorders of the Esophagus

Symptoms of esophageal disease

Chest pain, dysphagia, odynophagia, regurgitation.

Pathophysiology of GERD

Reflux of gastric contents due to transient LES relaxations, hypotensive LES, hiatal hernia, impaired clearance due to peristalsis or salivary function

GERD acid clearance mechanisms

Peristalsis, saliva/bicarbonate, gravity.

Hiatal hernia effect on GERD

Weakens LES, creates intrathoracic gastric pouch, reduces diaphragmatic pinch.

GERD complications

Erosions, ulcers, strictures, Barrett’s esophagus, adenocarcinoma.

GERD symptoms

Heartbuirn(pyrosis), Epigastric abdominal pain, regurgitation, nausea, bleching, dysphagia, chest pain, hiccups, respiratory symptoms

Clinical approach to heartburn

History, trial of PPI, lifestyle changes, EGD for alarm symptoms, pH monitoring if unclear.

Lifestyle modifications for GERD

Sleep on left side, avoid carbonated beverages, elevate head of bed, avoid late meals, avoid trigger foods, stop smoking, weight loss.

Pharmacologic therapy for GERD

Antacids, H2 blockers, PPIs (most effective).

Definition of Barrett’s esophagus

Intestinal metaplasia replacing normal squamous epithelium in distal esophagus.

Management of Barrett’s

PPI therapy for all; surveillance EGD every 3–5 years if no dysplasia; endoscopic therapy for LGD/HGD.

Barrett’s cancer risk sequence

Chronic inflammation → metaplasia → dysplasia → adenocarcinoma.

Common organisms in infectious esophagitis

Candida, HSV, CMV.

Candida esophagitis risk factors

Immunosuppression, diabetes, antibiotics, steroids.

Chest pain differential: esophageal

GERD, esophagitis, pill injury, radiation injury, Boerhaave’s, caustic ingestion, motility disorders.

Boerhaave’s syndrome

Full‑thickness esophageal rupture after forceful vomiting; severe chest pain; subcutaneous emphysema.

Caustic ingestion

Acids → stomach injury; alkali → esophageal injury; risk of perforation and strictures.

Oropharyngeal vs esophageal dysphagia

Oropharyngeal = difficulty initiating swallow; esophageal = food “stuck” in chest.

Symptoms of oropharyngeal dysphagia

Coughing, choking, nasal regurgitation, repeated swallows.

Causes of oropharyngeal dysphagia

Stroke, Parkinson’s, ALS, MG, polymyositis, Zenker’s diverticulum, decreased saliva.

Symptoms of esophageal dysphagia

Food sticking in chest; bland regurgitation without acid taste.

Schatzki ring

Thin mucosal ring at GE junction; intermittent solid food dysphagia.

Peptic stricture

Chronic GERD → fibrosis → progressive solid food dysphagia.

Zenker’s diverticulum

Outpouching above UES; regurgitation of undigested food; halitosis.

Definition of Eosinophilic Esophagitis

Solid‑food dysphagia + >15 eosinophils/HPF; young males; atopy.

Esophilic Esophagitis symptoms

Dysphagia, food impaction, chest pain.

Eosinophilic Esophagitis treatment

Elimination diet (6‑FED/4‑FED/2‑FED), PPI, topical steroids (fluticasone, budesonide), dupilumab.

Achalasia pathophysiology

Loss of inhibitory NO‑producing inhibitory neurons → No peristalsis + incomplete LES relaxation.

Achalasia symptoms

Solids and liquids dysphagia, regurgitation, chest pain, weight loss.

Achalasia manometry + imaging sign

Aperistalsis + incomplete LES relaxation. BIRDS BEAK

Achalasia treatment

Botox, pneumatic dilation, Heller myotomy, POEM.

Scleroderma esophagus pathophysiology

Smooth muscle atrophy + fibrosis → weak peristalsis + loose LES.

Scleroderma symptoms

Severe GERD, dysphagia, nocturnal aspiration.

Scleroderma treatment

Aggressive reflux control with PPIs; avoid smooth muscle relaxants; dilate strictures.

Nonspecific esophageal motility disorders

Chest pain, intermittent dysphagia; not progressive; associated with anxiety/depression.

Dysphagia algorithm

Solids only = mechanical obstruction; solids + liquids = motility disorder.