Gastroenterology and Hepatology Next Study Tips Read Key Points aggregated at the beginning of each section, then review detailed content by clicking on section headings. After reading detailed content, reinforce your knowledge with a final review of Key Points. Access questions related directly to the syllabus content by clicking on the Test Your Knowledge tabs. Contributors Please note that a "1" following a contributor's name indicates that he or she has no relationships to disclose. A "2" indicates that the contributor has disclosed relationships. Please scroll down to view all disclosures. 2 Steven K. Herrine, MD, FACP, Book Editor Professor of Medicine Division of Gastroenterology and Hepatology Thomas Jefferson University Philadelphia, Pennsylvania 1 Thomas Fekete, MD, FACP, Associate Editor Professor of Medicine Associate Professor of Microbiology Temple University Medical School Philadelphia, Pennsylvania 2 Brian P. Bosworth, MD Assistant Professor of Medicine Weill Medical College of Cornell University New York, New York 2 Patricia Kozuch, MD Assistant Professor of Medicine Division of Gastroenterology and Hepatology Thomas Jefferson University Philadelphia, Pennsylvania 2 David E. Loren, MD Assistant Professor of Medicine Division of Gastroenterology and Hepatology Thomas Jefferson University Philadelphia, Pennsylvania 2 Victor J. Navarro, MD Professor of Medicine, Pharmacology and Experimental Therapeutics Hepatology and Liver Transplantation Thomas Jefferson University Philadelphia, Pennsylvania 2 Amy S. Oxentenko, MD, FACP Assistant Professor of Medicine College of Medicine, Mayo Clinic Rochester, Minnesota 1 Patrick R. Pfau, MD Associate Professor of Medicine University of Wisconsin Madison, Wisconsin 2 Simona Rossi, MD Assistant Professor of Medicine Division of Gastroenterology and Hepatology Thomas Jefferson University Philadelphia, Pennsylvania Editor-in-Chief Patrick C. Alguire, MD, FACP1 Director, Education and Career Development American College of Physicians Philadelphia, Pennsylvania Gastroenterology and Hepatology Reviewers 1 Amindra S. Arora, MD 1 Raymond F. Bianchi, MD, FACP 2 Douglas Einstadter, MD, MPH, FACP 1 Asad Khan Mohmand, MD 2 Darrell S. Pardi, MD 2 Amir Qaseem, MD, PhD, MHA, FACP 1 Darius A. Rastegar, MD, FACP 2 Joel E. Richter, MD, FACP 1 Ingram M. Roberts, MD, FACP 2 Suzanne Rose, MD, MSEd, FACP Gastroenterology and Hepatology ACP Editorial Staff Charles Rossi, Senior Associate of Clinical Content Development Sean McKinney, Director, Self-Assessment Programs Margaret Wells, Managing Editor Katie Idell, Production Administrator/Editor ACP Principal Staff Steven E. Weinberger, MD, FACP2 Deputy Executive Vice President Senior Vice President, Medical Education and Publishing D. Theresa Kanya, MBA1 Vice President, Medical Education and Publishing Sean McKinney1 Director, Self-Assessment Programs Margaret Wells1 Managing Editor Charles Rossi1 Senior Associate of Clinical Content Development Becky Krumm1 Senior Staff Editor Ellen McDonald, PhD1 Senior Staff Editor Amanda Neiley1 Staff Editor Katie Idell1 Production Administrator/Editor Valerie Dangovetsky1 Program Administrator John Murray1 Editorial Coordinator Shannon O'Sullivan1 Editorial Coordinator Developed by the American College of Physicians 1. Has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. 2. Has disclosed relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. See below. Conflicts of Interest The following contributors and ACP staff members have disclosed relationships with commercial companies: Brian P. Bosworth, MD Stock Options/Holdings: Schering-Plough Research Grants/Contracts: Abbott, Centocor, Cerimon, PDL Biopharma, Salix, UCB, Procter & Gamble Douglas Einstadter, MD, MPH, FACP Consultantship: Medical Mutual of Ohio Steven K. Herrine, MD, FACP Research Grants/Contracts: Human Genome Sciences, Roche, Schering-Plough, Bristol-Myers Squibb, McNeil Consumer Products, Sanofi-Aventis Speakers Bureau: Roche, Schering-Plough Patricia Kozuch, MD Consultantship: UCB, Abbott Speakers Bureau: Scientific American Frontiers Research Grants/Contracts: Sub investigator for Abbott, Ocera, Celltech, Berlex, Otsuka, Prometheus, Given Imaging, Alba Therapeutics, AstraZeneca, Salix, PDL Biopharma; Primary investigator for Abbott, Centocor Other (Educational Speaking, Ad Board): UCB, Centocor, Abbott, Elan David E. Loren, MD Speakers Bureau: Olympus America, Boston Scientific Research Grants/Contracts: Boston Scientific, Protherics Victor J. Navarro, MD Consultantship: Merck, Alza, Amgen, Bristol-Myers Squibb, Theravance, Metabasis, Janssen, Viropharma, Johnson & Johnson Research Grants/Contracts: Alza, Biotrin, Bristol-Myers Squibb, Janssen, McNeil Consumer Products, Madaus Pharma, Merck, Metabasis, Roche, Sanofi-Aventis, Theravance Amy S. Oxentenko, MD, FACP Research Grants/Contracts: PDL Biopharma Darrell S. Pardi, MD Research Grants/Contracts: Salix, AstraZeneca, Procter & Gamble Consultantship: Biobalance Corporation, Lonza, Salix, Elan Amir Qaseem, MD, PhD, MHA, FACP Employment: American College of Physicians Honoraria: NovoNordisk Joel E. Richter, MD, FACP Honoraria: AstraZeneca, TAP Speakers Bureau: AstraZeneca, TAP Suzanne Rose, MD, MSEd, FACP Royalties: Hayes-Barton Press Consultantship: Takeda, Novartis Speakers Bureau: Takeda, TAP Simona Rossi, MD Research Grants/Contracts: Bristol-Myers Squibb, Human Genome Sciences, McNeil Consumer Products, Novartis Pharmaceuticals, Roche, Sanofi-Aventis, Schering-Plough, Gilead Sciences, Inc. Honoraria: Gilead Steven E. Weinberger, MD, FACP Stock Options/Holdings: Abbott, GlaxoSmithKline Disorders of the Esophagus Symptoms of Esophageal Disorders Gastroesophageal Reflux Disease Barrett Esophagus Esophageal Carcinoma Esophageal Motility Disorders Infectious, Pill-induced, and Eosinophilic Esophagitis Key Points Oropharyngeal dysphagia occurs immediately with deglutition and often has a neuromuscular origin. Esophageal dysphagia usually occurs after the initiation of a swallow and is often caused by a mechanical interference with swallowing. Dysphagia for solids is usually caused by a structural lesion; dysphagia for both solids and liquids is usually caused by a motility disorder. Odynophagia is usually caused by esophageal ulceration. Transient relaxation of the lower esophageal sphincter is an important cause of gastroesophageal reflux disease. Ambulatory pH monitoring is the gold standard for the diagnosis of gastroesophageal reflux disease. Empiric therapy with a proton pump inhibitor has an acceptable sensitivity and specificity for diagnosing gastroesophageal reflux disease. The standard of care for the medical treatment of gastroesophageal reflux disease is proton pump inhibitor therapy. Lifestyle modifications and surgical and endoscopic approaches are of unclear long-term benefit for gastroesophageal reflux disease. Up to one third of patients with gastroesophageal reflux disease have extraesophageal manifestations, such as asthma, noncardiac chest pain, chronic cough, and laryngitis. Upper endoscopy with biopsies is necessary to diagnose Barrett esophagus. Barrett esophagus is associated with a 30-fold increased risk of esophageal adenocarcinoma. Surveillance endoscopy with biopsy is recommended in patients with Barrett esophagus. Early detection and surgical resection of esophageal cancer offers the best chance for good outcome. Most esophageal cancers are detected at later stages and are treated with combined-modality therapy consisting of surgery and radiation therapy and/or chemotherapy. All patients with achalasia require esophagogastroduodenoscopy and biopsy to rule out cancer-related pseudoachalasia. Most esophageal motility disorders are hypertonic (spastic), of which the best characterized is achalasia. Pseudoachalasia mimics the manometric findings of achalasia but is caused by obstruction by an underlying malignancy. Patients with achalasia present with dysphagia and can be treated by disruption of the malfunctioning lower esophageal sphincter tone. Infectious esophagitis occurs in immunosuppressed patients and in persons with abnormal esophageal stasis. Odynophagia is the most common presenting symptom in infectious esophagitis, which is most frequently caused by Candida albicans. Pill-induced esophagitis is most frequently caused by tetracycline, iron sulfate, potassium, bisphosphonates, NSAIDs, and quinidine. Eosinophilic esophagitis is rapidly increasing in incidence and is associated with atopy. Symptoms of Esophageal Disorders Dysphagia Heartburn Noncardiac Chest Pain Odynophagia and Globus Sensation Next: Dysphagia Dysphagia Dysphagia, or difficulty swallowing, is a symptom whose prevalence increases with age, affecting up to 15% of persons older than 65 years and up to 50% of persons in chronic care facilities. Recurrent, frequent, or persistent dysphagia can be an alarm symptom and requires investigation. Dysphagia is classified as either oropharyngeal dysphagia (also called transfer dysphagia) or esophageal dysphagia. Each of the two kinds of dysphagia has distinct epidemiology, pathophysiology, and management implications. Next: Oropharyngeal Dysphagia Oropharyngeal Dysphagia Oropharyngeal dysphagia usually occurs immediately with deglutition and is often associated with a neuromuscular disorder; it usually consists