33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders

Key Takeaways Explain This Topic AI

Dysphagia must be immediately categorized into oropharyngeal (difficulty initiating a swallow, choking, coughing, wet vocal quality, or nasopharyngeal regurgitation; evaluated initially with a modified barium swallow / videofluoroscopic swallowing study) versus esophageal (food 'sticking' in the retrosternal chest seconds after swallowing).

Esophageal dysphagia is differentiated into mechanical obstruction (dysphagia primarily for solids that progresses over time to include liquids; evaluated initially with upper endoscopy or barium esophagram) versus motility disorders (dysphagia for both solids and liquids simultaneously from onset; diagnostic gold standard is high-resolution esophageal manometry).

Achalasia is characterized by immune-mediated loss of nitric oxide-producing inhibitory neurons in the myenteric plexus, causing aperistalsis and failure of the lower esophageal sphincter (LES) to relax (elevated integrated relaxation pressure on manometry); barium swallow demonstrates the classic smooth distal 'bird's beak' tapering with proximal esophageal dilation.

Acute infectious esophagitis in immunocompromised hosts presents with severe odynophagia: Candida albicans causes diffuse white mucosal plaques (treated with oral fluconazole); CMV causes large, shallow, linear longitudinal ulcers (treated with IV ganciclovir); and HSV produces multiple small, punched-out 'volcano' ulcers with raised edges (treated with oral or IV acyclovir).

Pill-induced esophagitis is triggered by caustic medications (doxycycline, bisphosphonates, potassium chloride, NSAIDs, ferrous sulfate) lodging in the mid-esophagus at the aortic arch; prevention requires taking pills with at least 8 oz of water and remaining upright for 30 minutes. Eosinophilic esophagitis (EoE) affects young atopic males presenting with solid food impaction, stacked circular rings ('trachealization'), and ≥15 eosinophils/HPF on biopsy, treated with topical swallowed fluticasone/budesonide slurries, elimination diets, PPIs, or dupilumab.

Last updated: September 2026

Clinical Evaluation & Classification of Dysphagia

Dysphagia—the subjective sensation of difficulty or obstruction during the passage of solids or liquids from the mouth to the stomach—is a high-yield clinical presentation in family medicine requiring rapid anatomical and functional localization.

Phases of Deglutition & Functional Anatomy

Deglutition comprises three coordinated phases:

Oral Phase (Voluntary) : Food bolus is masticated, lubricated with saliva, and propelled backward by the tongue into the oropharynx (innervated by cranial nerves V, VII, and XII).

Pharyngeal Phase (Involuntary Reflex) : Rapid neuromuscular reflex (<1 second) coordinated by the swallowing center in the medulla oblongata (nucleus ambiguus and solitary tract). Soft palate elevates to seal the nasopharynx; the larynx and hyoid bone pull superiorly and anteriorly, tilting the epiglottis downward to seal the laryngeal vestibule; vocal cords adduct; respiration temporarily ceases; and the upper esophageal sphincter (UES / cricopharyngeus) relaxes to allow bolus entry into the esophagus (cranial nerves IX, X, and XII).

Esophageal Phase (Involuntary) : Coordinated primary and secondary peristaltic waves propel the bolus down the esophagus, while the lower esophageal sphincter (LES) relaxes via nitric oxide (NO) and vasoactive intestinal peptide (VIP) release to permit entry into the gastric fundus.

Oropharyngeal vs. Esophageal Dysphagia

The initial and most crucial clinical distinction is determining whether the swallowing difficulty is oropharyngeal or esophageal in origin:

Clinical Feature Oropharyngeal Dysphagia (Transfer Dysphagia) Esophageal Dysphagia (Transport Dysphagia)

Anatomical Level of Defect Oral cavity, pharynx, or upper esophageal sphincter Esophageal tubular body or lower esophageal sphincter

Onset & Timing of Sensation Immediate (within <1 second) of attempting to swallow Delayed (2 to 5 seconds after) completing the swallow

Sensation Localization Cervical region, neck, suprasternal notch Retrosternal area, substernal chest, or xiphoid area

Cardinal Symptoms • Difficulty initiating the swallow (hesitation, multiple attempts); • Choking, coughing, sputtering immediately upon swallowing; • Nasopharyngeal regurgitation (fluids emerging through nose); • 'Wet', gurgly vocal quality post-swallow; • Drooling, sialorrhea, aspiration pneumonia • Sensation of food 'sticking' or hanging up behind the breastbone; • Chest pressure or discomfort; • Regurgitation of undigested bland food hours post-meal; • Patient points to retrosternal chest (though distal lesions can refer sensation to the suprasternal notch)

Predominant Etiologies • Neurologic : Ischemic stroke (CVA), Parkinson disease, Amyotrophic lateral sclerosis (ALS), Traumatic brain injury, Multiple sclerosis; • Myopathic : Myasthenia gravis, Polymyositis, Dermatomyositis; • Structural : Zenker diverticulum , Cricopharyngeal bar, Oropharyngeal carcinoma • Mechanical Obstruction : Esophageal adenocarcinoma, Squamous cell carcinoma, Peptic stricture, Schatzki ring , Eosinophilic esophagitis, Vascular ring; • Motility Disorder : Achalasia , Diffuse esophageal spasm, Hypercontractile (jackhammer) esophagus, Systemic sclerosis (scleroderma)

Initial Diagnostic Investigation Modified Barium Swallow (MBS) / Videofluoroscopic Swallowing Study (VFSS) Upper Endoscopy (EGD) OR Barium Esophagram

Caution

Sensory Localization Fallacy in Esophageal Dysphagia :

While food sticking localized to the lower retrosternal area reliably predicts a distal esophageal lesion, approximately 30% of patients with distal esophageal pathology (such as distal adenocarcinoma or lower esophageal rings) localize their sensation of sticking to the suprasternal notch . Therefore, a complaint of high cervical food sticking does not rule out distal esophageal disease and warrants thorough evaluation of the entire esophagus!

Esophageal Dysphagia: Mechanical Obstruction vs. Motility Disorders

Once esophageal dysphagia is established, the history reliably distinguishes mechanical luminal narrowing from neuromotor dysmotility: ESOPHAGEAL DYSPHAGIA EVALUATION

• Sensation of Food Sticking
• │
• ┌──────────────────────┴──────────────────────┐
• ▼ ▼
• SOLIDS ONLY INITIALLY SOLIDS AND LIQUIDS
• (Progressive over time) (Simultaneously from onset)
• │ │
• ▼ ▼
• MECHANICAL OBSTRUCTION MOTILITY DISORDER
• Progressive: Malignancy, Stricture • Intermittent: Spasm, Jackhammer
• Intermittent: Schatzki Ring, EoE • Progressive: Achalasia, Scleroderma
• │ │
• ▼ ▼
• INITIAL TEST: EGD INITIAL TEST: HIGH-RESOLUTION
• (Biopsy, dilate, visualize) ESOPHAGEAL MANOMETRY (HRM)
• 1. Mechanical Obstruction

Pattern : Dysphagia begins strictly for solid foods (bread, meat, dense solids). Over weeks to months, as the mechanical lumen narrows beyond critical diameter (<13 mm), dysphagia progresses to soft foods and eventually to liquids.

Progressive Mechanical Obstruction :

Esophageal Adenocarcinoma : Occurs in the distal third of the esophagus; linked to chronic gastroesophageal reflux disease (GERD), Barrett's esophagus (intestinal metaplasia with goblet cells), obesity, and tobacco. Manifests with rapid, relentless progression from solids to liquids accompanied by profound weight loss and iron deficiency anemia.

Esophageal Squamous Cell Carcinoma : Occurs predominantly in the proximal two-thirds (upper and middle) of the esophagus; strongly linked to chronic alcohol consumption, tobacco use, caustic ingestion, and achalasia.

Peptic Stricture : History of longstanding, severe heartburn and acid reflux that paradoxically improves as the stricture forms (the stricture acts as a physical barrier preventing acid reflux). Dysphagia progresses slowly over years without significant weight loss.

Intermittent Mechanical Obstruction :

Schatzki Ring (Lower Esophageal Mucosal Ring) : Concentric, smooth mucosal ring occurring precisely at the squamocolumnar junction (Z-line), almost always accompanied by a sliding hiatal hernia. Manifests with episodic, non-progressive dysphagia strictly to solids , classically presenting as acute meat bolus impaction ( "steakhouse syndrome" ) when the patient eats hurriedly while consuming alcohol. Lumen caliber: >20 mm is asymptomatic; 13 to 20 mm causes intermittent symptoms; <13 mm causes constant solid food dysphagia.

2. Esophageal Motility Disorders

Pattern : Dysphagia occurs for both solids and liquids simultaneously from disease onset .

Achalasia : Progressive solid and liquid dysphagia accompanied by regurgitation of bland, undigested food, nocturnal coughing, and weight loss.

Distal (Diffuse) Esophageal Spasm (DES) : Episodic, intermittent solid and liquid dysphagia triggered by hot or cold beverages and emotional stress, accompanied by severe, squeezing retrosternal chest pain that mimics acute myocardial infarction. Barium swallow displays a non-propulsive "corkscrew" or "rosary bead" esophagus .

Systemic Sclerosis (Scleroderma Esophagus) : Smooth muscle atrophy and extensive fibrous replacement of the muscularis propria in the distal two-thirds of the esophagus. Produces profound hypotensive lower esophageal sphincter (LES) and complete aperistalsis, resulting in devastating gastroesophageal reflux, severe erosive esophagitis, Barrett's esophagus, and peptic strictures.

Achalasia: Pathophysiology, Diagnosis & Management

Achalasia is the most well-characterized primary esophageal motility disorder, defined by failure of the lower esophageal sphincter (LES) to relax upon swallowing and complete absence of organized peristalsis in the esophageal body.

Pathophysiology

Characterized by inflammatory, immune-mediated degeneration and loss of inhibitory postganglionic ganglion cells in the myenteric (Auerbach) plexus of the distal esophagus.

The selective loss of neurons containing nitric oxide synthase (NOS) and vasoactive intestinal peptide (VIP) unmasks unopposed cholinergic stimulation (acetylcholine and substance P), resulting in failure of LES relaxation and elevated baseline basal LES tone.

Secondary achalasia ( Pseudoachalasia ) can closely mimic primary achalasia; it is caused by tumor infiltration at the gastroesophageal junction (most commonly gastric cardia adenocarcinoma) or by Trypanosoma cruzi infection ( Chagas disease , which also causes megacolon and dilated cardiomyopathy).

Diagnostic Evaluation

High-Resolution Esophageal Manometry (HRM) : The gold standard diagnostic modality (Chicago Classification v4.0). Required diagnostic criteria:

Incomplete LES Relaxation : Elevated Integrated Relaxation Pressure (IRP; typically >15 mmHg depending on manometry system);

Complete Aperistalsis : 100% failed peristaltic contractions in the esophageal body.

Barium Esophagram (Timed Barium Swallow) : Demonstrates dilated esophageal body with retained barium column, air-fluid level, absent peristaltic stripping waves, and smooth, symmetric distal tapering resembling a "bird's beak" or "pencil tip".

Upper Endoscopy (EGD) : Mandatory in all patients to definitively rule out pseudoachalasia (malignancy). Endoscopy reveals dilated esophagus with retained food residue; the gastroesophageal junction is tightly closed but easily "pops" open with gentle endoscope advancement (in contrast to malignancy, which resists passage).

Therapeutic Modalities

Treatment aims to reduce LES resting pressure to facilitate gravity-assisted esophageal emptying:

Laparoscopic Heller Myotomy with Partial Fundoplication (Dor or Toupet) : Surgical division of the circular muscle fibers of the LES; addition of a partial 180-to-270-degree anterior or posterior fundoplication prevents severe postoperative acid reflux.

Peroral Endoscopic Myotomy (POEM) : Advanced endoscopic technique creating a submucosal tunnel to perform myotomy of the inner circular muscle; provides exceptional relief of dysphagia with minimal invasiveness, though long-term PPI therapy is frequently required for post-procedure reflux.

Pneumatic Balloon Dilation : Graded endoscopic dilation utilizing large pneumatic balloons (30, 35, 40 mm) to tear circular LES muscle fibers. High efficacy, but carries a 1% to 3% risk of esophageal perforation .

Botulinum Toxin Injection : Endoscopic injection of botulinum toxin A (inhibits presynaptic acetylcholine release) into the LES. Highly effective short-term, but benefits wane within 6 to 12 months; strictly reserved for elderly, frail patients who are poor candidates for definitive surgical or pneumatic procedures.

Acute Infectious Esophagitis in Immunocompromised Hosts

Infectious esophagitis presents with acute-onset severe odynophagia (painful swallowing), retrosternal chest pain, and dysphagia, occurring predominantly in patients with advanced HIV/AIDS, solid organ or bone marrow transplants, hematologic malignancies, or prolonged systemic corticosteroid therapy.

Comparison of Infectious Esophagitis Pathogens

Pathogen Clinical Context Endoscopic Gross Appearance Histopathology & Cytology First-Line Antimicrobial Regimen

Candida albicans • Most common cause overall; • HIV (CD4 <200 cells/µL); • Inhaled corticosteroid use; • Diabetes mellitus Diffuse, discrete, elevated white-to-yellow mucosal plaques resembling cottage cheese; when scraped, reveals friable, erythematous, bleeding mucosa Direct smear or biopsy demonstrates budding yeast cells and branching pseudohyphae and true hyphae invading squamous epithelial cells (GMS or PAS stain) Oral Fluconazole 400 mg loading dose, then 200 to 400 mg PO daily for 14 to 21 days .; (Refractory/IV: IV Caspofungin or IV Voriconazole)

Cytomegalovirus (CMV) • Advanced HIV (CD4 <50 cells/µL); • Solid organ transplant; • Graft-versus-host disease Large, shallow, linear or longitudinal ulcerations , predominantly in the mid-to-distal esophagus; normal intervening mucosa Biopsy of the ulcer base shows enlarged endothelial and stromal cells with pathognomonic basophilic intranuclear inclusion bodies surrounded by a clear halo ('owl's eye') Intravenous Ganciclovir 5 mg/kg IV every 12 hours for 14 to 21 days; transition to oral Valganciclovir 900 mg PO BID upon clinical improvement.

Herpes Simplex Virus (HSV-1) • HIV, transplant, chemotherapy; • Can occur in young immunocompetent hosts as a self-limited outbreak Multiple small, deep, punched-out 'volcano' ulcers with elevated, rolled margins; early lesions appear as vesicles that rupture Biopsy of the ulcer edge / margin reveals multinucleated squamous giant cells, nuclear molding, chromatin margination, and Cowdry A eosinophilic inclusion bodies Oral Acyclovir 400 mg 5 times daily (or Valacyclovir 1,000 mg TID) for 14 days .; (Severe/Inpatient: IV Acyclovir 5 mg/kg q8h)

Important

Biopsy Location Board Rule for Viral Esophagitis :

For CMV , take biopsies from the ulcer BASE , because CMV infects vascular endothelial and mesenchymal stromal cells located in the granulation tissue of the ulcer bed.

For HSV , take biopsies from the ulcer MARGIN / EDGE , because HSV is a dermotropic virus that infects viable squamous epithelial cells at the periphery of the ulceration.

Pill-Induced (Caustic / Drug-Induced) Esophagitis

Pill-induced esophagitis is an acute focal esophageal mucosal injury caused by direct caustic chemical contact and localized hyperosmolar or acidic toxicity when an orally ingested medication remains in prolonged contact with the esophageal wall.

Culprit Medications & Chemical Mechanisms

Antibiotics : Doxycycline and Tetracycline hydrochloride (produce an extremely acidic solution with pH <3.0 when dissolved, inducing chemical mucosal coagulative necrosis); Clindamycin.

Bisphosphonates : Alendronate , risedronate (induces severe epithelial cell toxicity and focal deep ulceration).

Electrolytes : Potassium chloride (KCl) tablets (hyperosmolar erosion and direct cellular lysis).

Anti-Inflammatory Drugs : Aspirin and non-selective NSAIDs (direct topical cytotoxicity and inhibition of local mucosal prostaglandins).

Iron Supplements : Ferrous sulfate (direct mucosal oxidation and free radical generation, producing brown-black mucosal tattooing).

Cardiovascular : Quinidine, mexiletine.

Anatomic Localization & Risk Factors

Occurs classically at points of physiologic anatomical narrowing where transit is naturally delayed: most commonly in the mid-esophagus where the aortic arch and left mainstem bronchus cross the esophageal lumen, or at the level of the lower esophageal sphincter.

Precipitating Behaviors : Ingestion of tablets without water ("dry-swallowing") or with insufficient fluid (<1-2 ounces), and immediately retiring to bed or lying supine post-ingestion. Decreased salivary flow and absence of gravity during sleep cause the tablet to adhere to mid-esophageal squamous mucosa.

Clinical Presentation & Management

Presentation : Sudden onset of sharp, severe retrosternal chest pain and intense odynophagia developing hours after taking a medication at bedtime. Symptoms are so severe that patients refuse to swallow saliva.

Endoscopy : Reveals localized, discrete, circumscribed mucosal ulceration with normal surrounding mucosa, frequently with "kissing ulcers" on opposing mucosal walls.

Prevention & Patient Education :

• Take all pills with a full 8-ounce (240 mL) glass of water ;
• Remain completely upright (sitting or standing) for at least 30 minutes after ingestion;
• Never swallow medications immediately prior to going to sleep;

Switch to liquid oral formulations for patients with underlying esophageal dysmotility or strictures.

Treatment : Immediate discontinuation of the offending agent; supportive care with liquid sucralfate slurries (1 g PO QID) and proton pump inhibitors for 1 to 2 weeks.

Eosinophilic Esophagitis (EoE)

Eosinophilic esophagitis is a chronic, immune- and antigen-mediated inflammatory esophageal disease characterized clinically by symptoms of esophageal dysfunction and histologically by eosinophil-predominant inflammation.

Epidemiology & Immunopathogenesis

Demographics : Predominantly affects young males (aged 20 to 40 years) , with a male-to-female ratio of 3:1.

Atopic Triad : Up to 70% to 80% have a personal or family history of atopic conditions: allergic rhinitis, asthma, atopic dermatitis (eczema), or IgE-mediated food allergies.

Pathophysiology : Allergen-driven Th2-mediated allergic response . Food antigens penetrate a defective epithelial mucosal barrier, activating Th2 helper cells to secrete IL-4, IL-5, and IL-13 . IL-13 stimulates esophageal epithelial cells to produce eotaxin-3 (CCL26) , a potent chemokine that drives selective eosinophil migration, tissue infiltration, and degranulation. Prolonged eosinophil activation releases major basic protein and transforming growth factor-beta (TGF-β), driving subepithelial fibrosis, lamina propria remodeling, and fibrostenotic stricture formation.

Clinical Presentation & Endoscopic Findings

Presentation : Recurrent, intermittent dysphagia strictly to solid foods; repetitive, prolonged chewing and slow eating habits ("last person to finish a meal"); compensatory fluid consumption to wash down food boluses; and acute esophageal food bolus impaction ("steakhouse syndrome") requiring emergency endoscopic disimpaction.

Endoscopic Diagnostic Findings :

• Stacked circular rings ("trachealization" or "feline esophagus");
• Longitudinal linear furrows parallel to the long axis of the esophagus;
• Whitish punctate exudates or papules (representing dense microabscesses of eosinophils);
• Mucosal friability and fragility ("crepe paper" mucosa) , which tears easily upon gentle endoscope passage;

Narrow-caliber esophagus and distal fibrostenotic strictures.

Diagnostic Criteria (Updated Consensus Guidelines)

Diagnosis requires all three of the following criteria:

Symptoms of esophageal dysfunction (dysphagia, food impaction);

Esophageal biopsy demonstrating ≥15 eosinophils per high-power field (HPF) (~60 eosinophils/mm²) in at least one mucosal specimen;

Exclusion of non-EoE disorders that cause esophageal eosinophilia (GERD, eosinophilic gastroenteritis, Crohn disease, achalasia, infection).

Stepwise Management of EoE

Therapy aims to achieve both symptomatic relief and histologic remission (<15 eosinophils/HPF) to prevent irreversible transmural remodeling and strictures:

Proton Pump Inhibitors (First-Line Pharmacotherapy) :

High-dose PPI (e.g., Omeprazole 20 to 40 mg BID or Pantoprazole 40 mg BID) for 8 to 12 weeks.

Dual Mechanism : In addition to acid suppression, PPIs exert direct anti-inflammatory effects by inhibiting Th2-stimulated eotaxin-3 expression in esophageal epithelial cells independent of gastric pH.

Achieves histologic remission in 30% to 50% of patients (formerly termed PPI-responsive esophageal eosinophilia).

Topical Swallowed Corticosteroids (First-Line Pharmacotherapy) :

Topical corticosteroids deliver direct mucosal anti-inflammatory action with minimal systemic absorption:

Swallowed Fluticasone Propionate : 440 to 880 mcg twice daily. Administered via a metered-dose inhaler sprayed directly into the oral cavity and swallowed without a spacer, without inhaling.

Swallowed Budesonide Viscous Suspension : 1 to 2 mg twice daily. Oral respule mixed with sucralose (Splenda; 5 packets per 1 mg) or honey to form a thick, viscous slurry that coats the esophageal wall.

Crucial Patient Education : Patients must rinse their mouth with water and spit (without swallowing) after administration to prevent oral candidiasis, and must remain NPO (no eating or drinking) for at least 30 to 60 minutes after dosing.

Dietary Elimination Therapy :

Empiric Six-Food Elimination Diet (SFED) : Eliminates the six most common food allergen triggers: cow's milk, wheat/gluten, egg, soy, peanuts/tree nuts, and fish/shellfish for 6 to 8 weeks, followed by sequential food reintroduction with surveillance endoscopies. Achieves >70% remission.

Step-Up 2-4-6 Approach : Starts with eliminating the two most common culprits ( milk and wheat ), escalating to 4 and 6 foods only if remission is not achieved.

Targeted Biologic Therapy (Dupilumab) :

Dupilumab (Dupixent) : Fully human monoclonal antibody directed against the interleukin-4 receptor alpha (IL-4Rα) subunit , inhibiting both IL-4 and IL-13 signaling cascades.

Dosing : 300 mg administered subcutaneously once weekly.

Indications : FDA-approved for adults and pediatric patients aged ≥1 year weighing ≥15 kg with refractory EoE, severe recurrent strictures, or intolerance to topical therapies.

Endoscopic Balloon Dilation :

Indicated for dominant fibrostenotic strictures causing persistent solid food dysphagia despite anti-inflammatory therapy. Must be performed gently and conservatively with gradual balloon sizing due to increased risk of deep mucosal tears and esophageal perforation.

Loading diagram... Systematic Diagnostic & Therapeutic Algorithm for Dysphagia & Esophagitis