Esophageal Disorders
The esophageal domain tests whether you can separate symptoms from disease, interpret reflux and motility testing correctly, and commit to the right surveillance or endoscopic plan.
Reflux and Barrett esophagus
- A PPI response is not diagnostic. Objective testing is needed when symptoms are atypical, alarm features exist, or anti-reflux surgery is contemplated.
- Lyon Consensus 2.0 thresholds on pH-impedance off PPI: acid exposure time (AET) above 6% is conclusive, 4-6% is inconclusive, below 4% is normal. Supporting metrics are mean nocturnal baseline impedance under 1500 ohm and post-reflux swallow-induced peristaltic wave index under 61%.
- Los Angeles grade C or D esophagitis, peptic stricture and Barrett esophagus are conclusive mucosal evidence regardless of pH data.
- Barrett requires columnar-lined mucosa at least 1 cm above the gastroesophageal junction with intestinal metaplasia, described by Prague C and M criteria. Seattle protocol: jumbo forceps, four quadrants every 2 cm.
- Surveillance: no dysplasia every 3-5 years; low-grade dysplasia managed by ablation or 6-monthly surveillance confirmed by an expert pathologist; high-grade dysplasia requires endoscopic resection of visible lesions plus ablation.
Motility and eosinophilic disease
- Achalasia causes solid-then-liquid dysphagia, regurgitation and weight loss. Chicago Classification v4.0 requires elevated integrated relaxation pressure with absent peristalsis. Eckardt score grades severity; options are pneumatic dilation, Heller myotomy or POEM.
- Eosinophilic esophagitis: food impaction and dysphagia in atopic patients, with at least 15 eosinophils per high-power field in biopsies taken off PPI for 8 weeks from distal and mid esophagus. Treat with PPI, swallowed budesonide, dupilumab or dilation.
- Caustic ingestion: no emetics, no blind nasogastric tube; endoscopy within 12-24 hours, since grade 2b and 3 injury predicts stricture.
Worked example
A 38-year-old woman has heartburn despite 8 weeks of omeprazole 20 mg. Endoscopy is normal. Off PPI, pH-impedance shows AET 5.1%, 65 reflux episodes, baseline impedance 1180 ohm and PSPW index 40%. AET alone is inconclusive, but both adjunctive metrics are abnormal, so pathological reflux is supported. Continue optimized PPI and address weight and lifestyle rather than declaring the study normal.
Traps
- Treating an AET of 4-6% as diagnostic.
- Diagnosing eosinophilic esophagitis from on-PPI biopsies without excluding other causes of esophageal eosinophilia.
- Calling a barium bird-beak image diagnostic of achalasia without manometry.
- Biopsying Barrett segments with standard rather than jumbo forceps and inadequate sampling.