A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Question 1

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Question 2

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Question 3

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Question 4

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Definition of Dysphagia

Answer 4

Dysphagia: any difficulty swallowing, which can be divided into the following subtypes

Oropharyngeal dysphagia: difficulty initiating the swallowing process

Esophageal dysphagia: the impaired passage of solid food and liquid through the esophagus towards the stomach

Motility-related dysphagia: dysphagia due to a neurological or muscular defect

Structural dysphagia: dysphagia due to a mechanical or anatomical obstruction

Aphagia: the inability to swallow

Presbyphagia: the characteristic changes and mild decline in swallowing function seen in older adults; typically asymptomatic

Odynophagia: a painful sensation triggered by swallowing

Question 5

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Etiology of Oropharygneal dysphagia when it is motility related dysphagia

Answer 5

Neurological disorders
Stroke
Neurodegenerative diseases
Parkinson disease
Brain tumor
Traumatic brain injury

Muscular disorders
Myasthenia gravis
Progressive muscular dystrophies

Question 6

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Etiology of Oropharygneal dysphagia when it is Structural Dysphagia

Answer 6

Mucosal disorders
Local infection (e.g., epiglottitis, acute tonsillitis)
Corrosive injury (e.g., thermal or chemical burn)
Zenker diverticulum
Mucositis (e.g., caused by radiation therapy or chemotherapy)

Extramural disorders
Cricopharyngeal muscle spasm
Osteophytes
Thyroglossal duct cyst

Question 7

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Etiology of esophageal Dysphagia when it is Motility-related dysphagia

Answer 7

Achalasia
GERD
Esophageal hypermotility disorders
Mixed connective tissue diseases

Question 8

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Etiology of esophageal Dysphagia when it is Structural Dysphagia

Answer 8

Intraluminal disorders: impacted foreign object or food bolus

Mucosal disorders (intrinsic narrowing)
Esophagitis (e.g., infectious esophagitis, eosinophilic esophagitis, corrosive esophagitis, or secondary to GERD, chemotherapy, or radiotherapy)
Esophageal webs (e.g., in Plummer-Vinson syndrome)
Esophageal rings (e.g., Schatzki ring
Esophageal diverticulum
Autoimmune conditions (e.g., CREST syndrome, Crohn disease, Behcet disease, pemphigus syndromes)

Extrinsic compression
Thyromegaly, substernal thyroid
Hilar lymphadenopathy,
Neoplasia (e.g., mediastinal tumor, thyroid tumor)

Cardiac dysphagia: a group of cardiovascular anomalies that cause dysphagia due to compression of the esophagus

Hiatal hernia

Question 9

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Clinical Characteristics of Oropharyngeal Dysphagia

Answer 9

Difficulty initiating swallowing, which can lead to repeat swallow attempts

Predominantly experienced in the throat or neck

May be associated with coughing or a choking sensation early in the swallowing process.

Reduced cough reflex
Drooling
Nasal regurgitation
Voice changes (nasal speech, wet voice)
Recurrent pneumonia (aspiration pneumonia)
Malnutrition and/or anorexia

Question 10

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Clinical Characteristics of Esophageal Dysphagia

Answer 10

Symptoms occur seconds after swallowing

Predominantly experienced retrosternally

May be associated with coughing late in the swallowing process

Halitosis
Bolus impaction

Question 11

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Clinical Characteristics of Motility Related Dysphagia

Answer 11

Dysphagia predominantly with liquids (or liquids and solid food)

May be aggravated by cold foods

Intermittent symptoms or progression of symptoms over a long duration (months to years)

Question 12

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Clinical Characteristics of Structural Dysphagia

Answer 12

Dysphagia predominantly with solid food (or initially to solids that progressed to liquids)

May be aggravated by large food boli and dense food

Question 13

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Red Flags for Dysphagia

Answer 13

> 50 years of age at onset
Clinically significant involuntary weight loss
Symptom progression over a short period of time (e.g., < 4 months)
Evidence of GI bleeding
Recurrent vomiting
History of cance

Question 14

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

DX of Oropharyngeal Dysphagia

Answer 14

Modified barium swallow
Preferred test for suspected oropharyngeal dysphagia
Provides functional evaluation of swallowing and can be used to assess the risk of aspiration

Endoscopic evaluation of the nasopharynx
Structural assessment: nasopharyngeal laryngoscopy

Functional assessment: fiberoptic endoscopic evaluation of swallowing (FEES)
Supplementary modality to modified barium swallow
Direct assessment of the oropharyngeal phase of swallowing

Pharyngoesophageal high-resolution manometry
: Can help identify patients who are likely to benefit from a myotomy

Question 15

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

TX Oropharyngeal Dysphagia

Answer 15

Management is primarily supportive and should be tailored to each patient, focus on symptom control, minimize aspiration risk, and ensure adequate nutrition. Goals of care should be discussed before considering interventional therapy (including enteral feeding) for dysphagia in elderly patients

Swallowing rehabilitation: compensatory strategies aimed to direct the bolus towards the esophagus and minimize aspiration risk
- Postural techniques (e.g., eating upright, chin tuck , head turn
- Exercises and retraining of the tongue, jaw, and neck

Optimization of nutrition

Management of the underlying cause,

Aspiration prevention surgery
Consider in patients at a high risk of aspiration despite other supportive measures.
Examples include percutaneous endoscopic gastrostomy, tracheotomy, and endolaryngeal stenting

Question 16

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

DX Esophageal Dysphagia

Answer 16

Esophagogastroduodenoscopy (EGD): preferred initial test for most patients

Allows for direct visualization of mucosal lesions and structural abnormalities
Biopsies can be taken during the procedure. 

Esophageal barium swallow
If EGD is not immediately available
Suspected achalasia if manometry is not immediately available
Second-line test (adjunct) if initial EGD is normal

High-resolution esophageal manometry
Gold standard for diagnosing esophageal motility disorders
Suspected esophageal motility disorder in individuals with a normal EGD and barium swallow.

Thoracic imaging: if extrinsic esophageal compression is suspected (e.g., due to goiter, thoracic aortic aneurysm, mediastinal mass)

Question 17

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

TX Esophageal Dysphagia

Answer 17

Pharmacotherapy: e.g.,
PPI for reflux esophagitis
Smooth muscle relaxants for esophageal motility disorders
Swallowed aerosolized steroids for eosinophilic esophagitis

Endoscopic intervention
Botox injections: to control hypertonia
Dilation: for etiologies that cause significant narrowing (e.g., achalasia, esophageal rings or webs, strictures)
Diverticulotomy: for esophageal diverticula

Surgery
Myotomy: Consider for refractory esophageal hypermotility disorders.
Curative or palliative tumor resection (e.g., in pharyngeal cancer or esophageal cancer)
Surgical resection of refractory rings and/or strictures

Supportive therapy: Optimize nutrition of patients with dysphagia refractory to therapy.
Diet modification as needed (e.g., pureeing solid food, taking small bites, chewing carefully).
Consider temporary nasogastric tube feeding (e.g., in patients with acute stroke).

Question 18

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Dysphagia Complications

Answer 18

Esophageal bolus impaction: usually manifests as acute dysphagia

Aspiration pneumonia: common complication of oropharyngeal dysphagia

Malnutrition

Question 19

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Dysphagia + aspiration + coughing while swallowing — what’s the most likely cause?

Answer 19

Oropharyngeal dysphagia, especially neurologic (e.g., post-stroke, Parkinson’s)

Question 20

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

A patient reports progressive dysphagia starting with solids, now includes liquids. What’s your concern?

Answer 20

Esophageal cancer — red flag!

Question 21

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Dysphagia + chest pain + intermittent symptoms that are non-progressive. Diagnosis?

Answer 21

Esophageal spasm or Schatzki ring

Question 22

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Patient has scleroderma and severe reflux. What’s the mechanism?

Answer 22

Decreased LES tone + absent peristalsis (smooth muscle atrophy)

Question 23

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

“How do you distinguish achalasia from cancer on imaging?”

Answer 23

Bird-beak narrowing = achalasia

Shoulder sign or mucosal irregularity = suspect malignancy

Always do EGD to rule out cancer in suspected achalasia (pseudoachalasia)

Question 24

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux

Heartburn Definition

Answer 24

Burning retrosternal discomfort, commonly after meals, worsened by bending or lying down. It is the typical symptom in GERD, along with regurgitation.

Heartburn (or pyrosis) is used to describe predominantly esophageal symptoms

Question 25

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux Gastrointestinal Reflux Defintion

Answer 25

Gastroesophageal reflux: regurgitation of stomach contents into the esophagus (can also occur in healthy individuals, e.g., after consuming greasy foods or wine)

Question 26

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux GERD Definition

Answer 26

Gastroesophageal reflux disease (GERD) A condition in which reflux causes troublesome symptoms (typically including heartburn or regurgitation) and/or esophageal injury/complications The most common endoscopic finding associated with esophageal mucosal injury is reflux esophagitis.

Question 27

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux GERD Risk Factors

Answer 27

Smoking, caffeine and alcohol consumption Stress Obesity Pregnancy Angle of His enlargement (> 60°) - The angle of His describes the angle that is formed between the esophagus and the gastric fundus (esophageal-gastric angle). In healthy adults, it is 50–60°. Iatrogenic (e.g., after gastrectomy) Inadequate esophageal protective factors (i.e., saliva, peristalsis) Gastrointestinal malformations and tumors: gastric outlet obstruction, gastric cardiac carcinoma Scleroderma Sliding hiatal hernia: ≥ 90% of patients with severe GERD Asthma

Question 28

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux GERD Pathomechanisms

Answer 28

Gastroesophageal junction dysfunction can occur because of the following factors: - Increased frequency of transient lower esophageal sphincter relaxations (TLESRs) - TLESRs allow venting of accumulated gases to prevent distention of the stomach. - In individuals with GERD - About two-thirds of TLESRs are also accompanied by reflux of gastric content. Imbalance between intragastric and lower esophageal sphincter (LES) pressures - Reflux occurs when the intragastric pressure is higher than that created by the LES. - LES tone can be decreased by substances such as caffeine and nitroglycerin, as well as by conditions that cause denervation of the muscle layer, such as scleroderma - Intragastric pressure is increased in pregnancy, delayed gastric emptying, and obesity, among other conditions. Anatomic abnormalities of gastroesophageal junction (e.g., hiatal hernia, tumors) Impaired esophageal acid clearance -Normally, acid reflux is neutralized by salivary bicarbonate and evacuated back to stomach via esophageal peristalsis. - Clearance can be disrupted by reduced salivation (e.g., due to smoking) and/or decreased peristalsis (e.g., due to inflammation).

Question 29

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux Pathology of GERD

Answer 29

Transformation of squamous into columnar epithelium leads to Barrett metaplasia

Question 30

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux GERD Clinical Features

Answer 30

Typical symptoms - Retrosternal burning pain (heartburn) - Regurgitation - Dysphagia, odynophagia - Water brash: a symptom of excessive salivation triggered by refluxing of stomach acid Extraesophageal symptoms - Chronic nonproductive cough and nighttime cough - Hoarseness - Bronchospasm - Dental erosion

Question 31

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux Red Flag Symptoms of GERD

Answer 31

Dysphagia, odynophagia Anemia and/or signs of GI bleeding (e.g., hematemesis, hematochezia) Unintentional weight loss Vomiting Presence of > 1 risk factors for Barrett esophagus

Question 32

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux GERD DX

Answer 32

Esophagogastroduodenoscopy - A procedure in which a flexible fiber-optic endoscope is passed through the mouth and oropharynx to visualize the mucosa of the esophagus, stomach, and, sometimes, the duodenum. Commonly used to diagnose and manage upper gastrointestinal disorders, monitor precancerous syndromes, and guide endoscopic percutaneous feeding tube placement Esophageal pH monitoring - can be used to objectively identify abnormal reflux of gastric content into the esophagus; however, it is not a routine diagnostic test. Esophageal barium swallow- Consider if the main symptom is dysphagia or if there is suspicion of structural abnormalities (e.g., esophageal rings or webs) or motility disorders (e.g., achalasia, distal esophageal spasm) Esophageal manometry - A diagnostic test that is used to evaluate the peristaltic function of the esophagus during swallowing. The propagation, speed, and vigor of the peristaltic wave is measured via an esophageal catheter fitted with pressure sensors every 3–6 cm. Consider if achalasia or esophageal hypermotility disorders are suspecte

Question 33

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux GERD TX

Answer 33

PPIs: standard dose of PPI for 8 weeks Indications - Empiric PPI trial in patients with typical symptoms - After EGD: ERD or presumed Nonerosive reflux disease (NERD) H2 receptor antagonists: Consider as alternate maintenance therapy for NERD, or in addition to PPIs to control nighttime symptoms Maintenance therapy: lowest effective dose of acid suppression medication Lifestyle Chnages

Question 34

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux GERD TX Surgery

Answer 34

Fundoplication - an antireflux procedure in which the gastric fundus is wrapped around the lower esophagus and secured with stitches to form a cuff; results in a narrowing of the distal esophagus and the gastroesophageal junction (GEJ), preventing reflux

Question 35

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux GERD Complications

Answer 35

Barrett esophagus - intestinal metaplasia of the esophageal mucosa due to chronic reflux esophagitis Columnar epithelium and goblet cells rather than esophageal squamous epithelium on histopathological examination A precancerous condition that requires close surveillance Reflux esophagitis: most common complication of GERD Erosive esophagitis Iron deficiency anemia: mucosal erosions and ulcerations → chronic bleeding → anemia Esophageal stricture Esophageal rings: e.g., Schatzki rings - Narrowing of the esophagus Can lead to dysphagia

Question 36

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux Can GERD cause asthma?

Answer 36

Yes — acid microaspiration or vagal reflex can trigger bronchospasm.

Question 37

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux Patient has new-onset hoarseness and sore throat, no heartburn. Can this still be GERD?

Answer 37

Yes — Laryngopharyngeal reflux (LPR) is a variant where reflux affects upper airway.

Question 38

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux Why might someone with GERD have normal endoscopy?

Answer 38

Many patients have non-erosive reflux disease (NERD) — diagnosis requires pH testing.

Question 39

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux Patient with GERD symptoms fails PPI. Next step?

Answer 39

Check adherence and timing (must be taken before meals) If still symptomatic → EGD or pH study

Question 40

A.24 Dysphagia, Heartburn, Gastrointestinal Reflux Why is long-term PPI use monitored?

Answer 40

Risk of: Nutrient malabsorption (Mg, Ca, B12) ↑ risk of C. difficile Kidney disease (rare) Possible osteoporosis