Study guide
3.1 Esophageal Disease
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
3.1 Esophageal Disease
Key Takeaways Explain This Topic AI
The esophageal blueprint subsection enumerates reflux, Barrett esophagus, esophageal cancer screening, motility disorders, medication-induced injury, diverticula, strictures and webs, varices, infectious esophagitis, Mallory-Weiss syndrome and eosinophilic esophagitis.
Alarm features such as dysphagia, odynophagia, weight loss, bleeding or anemia require endoscopy rather than empiric acid suppression.
Barrett esophagus surveillance is stratified by dysplasia grade, and dysplastic Barrett is treated endoscopically rather than surveilled indefinitely.
Achalasia is confirmed by manometry showing incomplete lower esophageal sphincter relaxation with absent peristalsis, after pseudoachalasia from malignancy is excluded.
Eosinophilic esophagitis presents with solid-food dysphagia and food impaction in an atopic patient and is diagnosed by esophageal biopsy despite a normal-appearing mucosa.
Last updated: August 2026
Upper gastrointestinal disorders represent a major portion of the ABIM Internal Medicine examination. Mastery of these topics requires understanding exact diagnostic criteria, guideline-directed surveillance intervals, modern pharmacotherapy, and algorithmic emergency resuscitation.
- 1. Esophageal Disorders
- Gastroesophageal Reflux Disease (GERD)
Gastroesophageal Reflux Disease (GERD) occurs when gastric contents flow retrograde into the esophagus, causing troublesome symptoms (heartburn, acid regurgitation) or mucosal injury (erosive esophagitis, strictures, Barrett esophagus).
Diagnostic Approach
Typical Symptoms (Heartburn, Acid Regurgitation): Clinical diagnosis is sufficient. Initiate an empiric trial of once-daily oral Proton Pump Inhibitor ( PPI , e.g., Omeprazole 20–40 mg, Pantoprazole 40 mg, or Esomeprazole 40 mg) taken 30–60 minutes before breakfast for 4 to 8 weeks .
Lifestyle Modifications: Weight loss in overweight/obese patients, head-of-bed elevation (6–8 inches), avoidance of late-evening meals (within 2–3 hours of sleeping), and elimination of trigger foods (caffeine, chocolate, alcohol, citrus, spicy/fatty foods).
Indications for Early Esophagogastroduodenoscopy (EGD):
Red Flag / Alarm Symptoms: Progressive dysphagia, odynophagia, persistent vomiting, unintentional weight loss, evidence of GI bleeding, or unexplained iron deficiency anemia.
Refractory Symptoms: Persistence of classic symptoms despite 8 weeks of optimized twice-daily PPI therapy.
Barrett Esophagus Screening: Men aged >50 years with chronic GERD symptoms (>5 years) and ≥ 2 \ge 2 ≥ 2 additional risk factors: Caucasian race, central adiposity (elevated BMI/waist circumference), current/past history of tobacco smoking, or a first-degree family history of Barrett esophagus or esophageal adenocarcinoma.
Barrett Esophagus
Barrett Esophagus is the replacement of normal stratified squamous epithelium of the distal esophagus by specialized intestinal metaplasia containing goblet cells , predisposing to esophageal adenocarcinoma. Normal Stratified Squamous Epithelium ➔ Specialized Intestinal Metaplasia (Goblet Cells) ➔ Low-Grade Dysplasia ➔ High-Grade Dysplasia ➔ Esophageal Adenocarcinoma
Endoscopic & Histopathologic Surveillance
Histopathology Recommended Surveillance / Management Strategy
Non-Dysplastic Barrett Esophagus (NDBE) Surveillance EGD every 3 to 5 years with 4-quadrant biopsies every 2 cm.
Indefinite for Dysplasia Optimize acid suppression with high-dose PPI for 3–6 months to heal acute inflammation, then repeat surveillance EGD in 3 to 6 months .
Low-Grade Dysplasia (LGD) (confirmed by 2 expert pathologists) Endoscopic Eradication Therapy (EET) with Radiofrequency Ablation ( RFA ) is preferred; alternative is surveillance EGD every 6 to 12 months .
High-Grade Dysplasia (HGD) (confirmed by 2 expert pathologists) Endoscopic Eradication Therapy (EET) is mandatory: Endoscopic Mucosal Resection ( EMR ) for any visible nodular/focal lesions, followed by RFA of all remaining flat Barrett mucosa.
Intramucosal Carcinoma (T1a) Endoscopic mucosal resection (EMR) / endoscopic submucosal dissection (ESD) followed by ablation of residual metaplasia.
Eosinophilic Esophagitis (EoE)
Eosinophilic Esophagitis is a chronic, immune-mediated, antigen-driven inflammatory disorder of the esophagus.
Clinical Presentation: Typically affects young adults (males > females, ages 20–40) with a history of atopy (asthma, allergic rhinitis, atopic dermatitis, food allergies). Presenting complaints include progressive dysphagia to solid foods, recurrent food impactions requiring emergency endoscopic disimpaction, central chest pain, and refractory heartburn.
Diagnostic Criteria:
Symptoms of esophageal dysfunction.
Endoscopic biopsy demonstrating ≥ 15 \ge 15 ≥ 15 eosinophils per high-power field (HPF) in one or more mucosal biopsy specimens (from proximal and distal esophagus).
Exclusion of secondary causes of esophageal eosinophilia (eosinophilic gastroenteritis, Crohn disease, achalasia, infection, hypereosinophilic syndrome).
Endoscopic Findings: Concentric circular rings ("trachealization" or "feline esophagus"), linear vertical furrows, white plaques/exudates (eosinophil microabscesses), strictures, and mucosal fragility ("crepe-paper" mucosa).
Treatment Modalities:
Swallowed Topical Corticosteroids: Fluticasone propionate (swallowed from MDI without a spacer, 440–880 mcg BID) or oral viscous Budesonide slurry (1–2 mg daily mixed with Splenda/sucralose) for an initial 8–12 week induction course.
High-Dose PPI: E.g., Omeprazole 20–40 mg BID (acts both by reducing acid and downregulating Th2 inflammatory cytokine eotaxin-3).
Dietary Elimination: Empiric 6-food elimination diet (dairy, wheat, eggs, soy, nuts, seafood) or 2-food elimination diet (dairy and gluten).
Biologic Therapy: Dupilumab (monoclonal antibody targeting IL-4 receptor alpha, blocking IL-4 and IL-13 signaling), subcutaneous weekly injection approved for adults and adolescents ≥ 12 \ge 12 ≥ 12 years with refractory EoE.
Endoscopic Dilation: Gentle balloon dilation for symptomatic fibrostenotic strictures.
Esophageal Motility Disorders Dysphagia to Solids ONLY ➔ Mechanical Obstruction (Schatzki ring, Peptic stricture, Esophageal Cancer)
Dysphagia to Solids AND Liquids ➔ Neuromuscular / Motility Disorder (Achalasia, Diffuse Esophageal Spasm, Scleroderma)
Achalasia
Pathophysiology: Autoimmune inflammatory degeneration of inhibitory ganglion cells within the myenteric (Auerbach's) plexus , resulting in loss of nitric oxide and vasoactive intestinal peptide (VIP) release. This causes failure of the Lower Esophageal Sphincter (LES) to relax and absence of peristalsis in the esophageal body.
Clinical Features: Insidious, progressive dysphagia to both solids and liquids , regurgitation of undigested food and saliva, nocturnal cough, non-cardiac chest pain, and weight loss.
Diagnostic Workup:
Barium Esophagram (Swallow): Dilated esophageal body with smooth, symmetrical, tapered narrowing at the gastroesophageal junction ( "bird's beak" sign ).
High-Resolution Manometry (HRM - Gold Standard): Elevated Integrated Relaxation Pressure ( IRP >15 mmHg ), indicating incomplete LES relaxation, and 100% aperistalsis in the distal esophageal body.
Chicago Classification Subtypes: Type I (Classic, absent pressurization), Type II (Panesophageal pressurization; best clinical response to treatment), Type III (Spastic/premature contractions).
Mandatory EGD: Must be performed in all patients to rule out Pseudoachalasia (secondary achalasia caused by adenocarcinoma of the gastric cardia or distal esophagus invading the myenteric plexus, especially in patients >60 years old with rapid symptom onset <6 months and severe weight loss).
Therapeutic Interventions:
Low Surgical Risk: Graded Pneumatic Balloon Dilation (30 mm, 35 mm, 40 mm), Laparoscopic Heller Myotomy with partial fundoplication (Dor or Toupet), or Peroral Endoscopic Myotomy (POEM) .
High Surgical Risk / Frail: Endoscopic injection of Botulinum toxin into the LES (temporary efficacy 6–12 months), or oral smooth muscle relaxants (calcium channel blockers, nitrates) before meals.
Diffuse Esophageal Spasm (Distal Esophageal Spasm)
Pathophysiology: Uncoordinated, high-amplitude, simultaneous esophageal contractions caused by impaired inhibitory neural signaling.
Clinical Presentation: Intermittent non-cardiac retrosternal chest pain (mimicking angina) and dysphagia to both solids and liquids, often precipitated by ingestion of very hot or ice-cold liquids or emotional stress.
Diagnostics: Barium swallow demonstrates a "corkscrew" or "rosary bead" esophagus . High-resolution manometry reveals normal IRP with ≥ 20 % \ge 20\% ≥ 20% premature contractions (distal latency <4.5 seconds).
Treatment: Calcium channel blockers (Diltiazem 60–90 mg TID), sublingual nitroglycerin PRN, tricyclic antidepressants (Imipramine 25–50 mg qhs for visceral pain neuromodulation), and peppermint oil.