Esophagitis

GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.

Eosinophilic esophagitis is a chronic, immune/antigen-mediated disease of the esophagus that presents with solid-food dysphagia and food impaction in young atopic men, diagnosed by endoscopic biopsy showing 15 or more eosinophils per high-power field after excluding other causes. Management follows the three D's: dietary elimination, drug therapy with a PPI and/or swallowed topical corticosteroids, and dilation for fibrostenotic strictures.

Barrett esophagus is metaplasia of the distal esophageal squamous lining into intestinal columnar epithelium driven by chronic GERD, and it is the established precursor of esophageal adenocarcinoma. Diagnosis requires endoscopy showing salmon-colored mucosa above the gastroesophageal junction confirmed by biopsy showing intestinal metaplasia with goblet cells, and management, from surveillance interval to endoscopic ablation, is dictated entirely by the graded dysplasia.

Esophageal stricture is a fixed luminal narrowing that produces progressive dysphagia to solids, most often a benign peptic stricture from chronic reflux but always requiring endoscopy with biopsy to exclude malignancy. Management is endoscopic dilation of the narrowed segment plus treatment of the underlying cause, with stenting or resection reserved for malignant obstruction.

Dysphagia is difficulty swallowing, and the history alone localizes it to oropharyngeal disease, marked by choking or nasal regurgitation at the start of a swallow, or esophageal disease, marked by food sticking seconds later. Esophageal dysphagia with solids alone points to a mechanical obstruction worked up first with upper endoscopy, while dysphagia for solids and liquids together points to a motility disorder worked up with barium esophagram and manometry.

Esophageal cancer comprises squamous cell carcinoma, driven by tobacco, alcohol, and caustic or motility injury to the upper and mid esophagus, and adenocarcinoma, arising from GERD-driven Barrett esophagus distally, both presenting with progressive dysphagia from solids to liquids plus weight loss. Diagnosis is by upper endoscopy with biopsy, staged with CT, PET, and endoscopic ultrasound, and treatment is stage-directed from endoscopic resection through esophagectomy with perioperative chemotherapy or chemoradiation to palliative chemoradiation and stenting.

Achalasia is a primary esophageal motility disorder from myenteric plexus degeneration that causes failure of lower esophageal sphincter relaxation and aperistalsis, producing dysphagia to solids and liquids with regurgitation. Diagnosis requires endoscopy to exclude pseudoachalasia followed by esophageal manometry, and definitive treatment is pneumatic dilation, laparoscopic Heller myotomy, or POEM.

Mallory-Weiss syndrome is a partial-thickness, longitudinal mucosal tear at the gastroesophageal junction caused by forceful retching or vomiting, classically presenting as hematemesis after an initial bout of non-bloody vomiting in a patient with alcohol use disorder or bulimia. Upper endoscopy is both diagnostic and therapeutic, most tears stop bleeding spontaneously, and active bleeding is controlled endoscopically.