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Gastroenterology and HePatologY Dysphagia Diagnosis Dysphagia is defined as difficulty swallowing and is classified as oropharyngeal or esophageal. Oropharyngeal Dysphagia . difficulty initiating swallowing . coughing, choking, and nasal regurgitation offluids . muscular or neurologic disorders, most commonly stroke, Parkinson disease Videofluoroscopy is used to evaluate suspected oropharyngeal dysphagia. Esophageal Dysphagia . food "sticking" or discomfort in the retrosternal region . mechanical obstruction or a motility disorder Solid-food dysphagia suggests a structural esophageal abnormality. Solid-food and liquid dysphagia or Iiquid dysphagia alone suggests an esophageal motility abnormality, such as achalasia. Solid food dysphagia that occurs episodically for years suggests an esophageal web or a distal esophageal ring (Schatzki ring) Progressively increasing solid-food dysphagia for several months suggests a peptic stricture or carcinoma. Treatment Oropharyngeal dysphagia is managed with dietary adjustment and speech therapy. Therapy for esophageal dysphagia is dictated by the underlying cause. TESTYOURSETF A 75 year-old man with Parkinson disease has difficulty initiating a swallow. ANSWER: For diagnosis, choose oropharyngeal dysphagia; for management, order oropharyngeal videofluoroscopy. 82

Gastroenterology and HePatologY DOil'T BETRIGKED . Chest pain is common in patients with GERD, but a cardiac cause of chest pain must be ruled out first' o In patients without alarm features, GERD management consists of once-daily PPI; twice-daily PPI for 4-8 weeks is indicated in patients not responding to once-daily treatment. TESTYOURSELF A 34-year-old woman has frequent heartburn. She has tried a PPI, once before breakfast and once before dinner, without improvement' ANSWER: For management, order upper endoscopy and, if normal, 24-hour esophageal pH monitoring while the patient is taking a PPI. Barrett Esophagus Screening Screen men aged >50 years with GERD symptoms for more than 5 years and additional risk factors (nocturnal reflux symp- toms, hiatal hernia, elevated BMI, tobacco use, intra-abdominal distribution of fat) to detect BE. Diagnosis The diagnosis of BE is based on endoscopic tissue biopsy. Treatment Treat patients with BE without dysplasia with a PPI. Endoscopic ablation or mucosal resection is recommended for patients with confirmed low- or high-grade dysplasia. Follow-up In patients with BE and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals of 12 months are indicated in patients with BE and low grade dysplasia who do not choose endoscopic ablation. DO['T BE TRICKED . Women with GERD do not require routine screening for BE. o Do not select antireflux surgery to prevent the progression of BE to adenocarcinoma Esophagitis Diagnosis Odynophagia is the most common presenting symptom of esophagitis. Cqndida olbicons is the most common infectious cause, followed by CMV and HSV r Diagnosis is based on compatible symptoms and oral candidiasis. ' Patients with oral candidiasis and odynophagia are treated empirically. 84 \

Gastroenterology and Hepatology Viral esophagitis is found in immunodeficient or immunosuppressed patients, and ulcerative oropharyngeal lesions are rare. Pill induced esophagitis may be caused by tetracyclines, NSAIDs, potassium chloride, iron, and alendronate. Severe substernal chest pain with swallowing occurs several hours to days after taking the medication. Young adults with eosinophilic esophagitis (EE) present with severe dysphagia and food impaction. Other atopic conditions, such as asthma, rhinitis, dermatitis, and sea sonal or food allergies, are common. Testing Esophageal Candida: Wh ite m ucosa I plaque-l i ke lesions consistent wilh Candida are seen on upper Perform upper endoscopy with biopsy/brushing if empiric therapy for esophagitis is endoscopy. unsuccessful. Upper endoscopy in patients with EE may show mucosal furrowing, stacked circular rings, white specks, and mucosal friability. Endoscopic biopsies show marked infiltration with eosinophils. TESTYOURSELF A 30 year-old man has frequent heartburn and recurrent episodes of food impaction. ANSWER: For diagnosis, choose eosinophilic esophagitis; confirm with upper endoscopy and biopsy. DON'T BE TRICKED . The absence oforal Candida lesions does not rule out esophageal candidiasis. Treatment Address the underlying cause ofesophagitis: . fluconazole or itraconazole for esophageal candidiasis . acyclovir, famciclovir, or valacyclovir for HSV esophagitis o ganciclovir or valganciclovir for CMV esophagitis . PPI. swallowed fluticasone, or budesonide for EE . supportive care for pill esophagitis TEST YOURSELF A 28 year-old man with HIV infection has a 2-month history of odynophagia. On physical examination, oral thrush is present' ANSWER: For diagnosis, choose Candida esophagitis. For treatment, select fluconazole. Peptic Ulcer Disease Diagnosis Most PUD is caused by Helicobacter pylori infection or NSAID use. AII patients with PUD should be tested fot H- pyloriinfection regardless of NSAID use' 85