DYSPHAGIA: 3 questions needs to be defined: 
  • Location of Dysphagia
    • Orophyrangeal or 
    • Esophageal; 
  • If Esophageal mechanism of dysphagia- 
    • Mechnical (only solid) or 
    • Motor (Both Solid and/or Liquid) - 
  • Then characteristics of dysphagia
    • progressive or 
    • intermittent or non-progressive

Additional References: 

GERD: Esophageal vs. Extra-esophageal Syndromes (with associated esophageal symptoms)
  • Alarm symptoms (dysphagia, anemia, weight loss, vomiting)
    • Present - Refer to GI for EGD
    • Absent - Therapeutic Trial with PPI and dietary rec. - If no or incomplete response, refer to Up-to-date algorithm
  • Severe GERD
    • What is the most effective treatment for severe gastro-oesophageal reflux disease? BMJ 2015
    • Clinical Pearls:
      • PPI should preferably be given before the first meal of the day ( when H-K-ATPase present in parietal cell is greatest after a prolonged fast, and parietal cells are stimulated post-prandially to secrete acid)
      • PPI should not be given with other acid suppresants.
      • PPI can be given twice a day (before evening meal) if needed and is useful especially in the first few days
      • PPI has its maximum effect (around 65%) after 5 days; normal acid secretion is restored after 24 - 48 hr 
      • H2B work best for PRN (due to rapid onset action) ; PPI are not good for PRN dosing


GERD Initial Management Algorithm (Figure 6, MKSAP 16) 

Management algorithm of GERD patient who failed PPI once daily Up-To-Date
GERD Lancet 2013 (LA Classification of reflux esophagitis)
GERD Lancet 2013 (Algorithm for alarm or refractory symptoms) 

GERD related complications

Barrett’s Esophagus NEJM 2014
Motility Disorders

Eiosinophilic Esophagitis (EoE)

  • Orophyrangeal vs  (CN 5, 10, 11, 12) 
    • Modified Barius Swallow vs FEES (done by speech therapy; direct observation) 
    • DDx. 
      • Iatrogenic
      • Infection
      • Metabolic: Amyloid 
      • Myopathic
      • Neurological
      • Structural Disease : Zenkers, Cervical web, osteophytes 
  • Esophgeal 
    • EGD vs Barium Swallow (can stick and coat) 
      • Hence, Barium Swallow is avoided if suspecting food impaction 
    • Mechanical 
      • Instrinsic
      • Extrinsic
    • Dysmotility 
Pressure Measurement

      • Chicago Classification of Esophageal Motility 
      • 36 cm, each cm has a sensor
      • Achalasia 
        • 3 types 
            • Type 1 :No motility at all, no relaxation of EGJ 
            • Type 2: Pressure generation is there, but Absent peristalsis, no relaxation of EGJ 
              • Best prognosis
            • Type 3: Spastic achalasia, no relaxation of EGJ
              • Worst prognosis 
  • Esophageal webs
  • Dysphagia 
  • Iron Deficiency