esophagitis occurs more often in the young or the elderly and often produces one or more discreet esophageal ulcers with normal surrounding mucosa. Commonly, the site of the ulceration is at the junction of the proximal and mid esophagus, where the amplitude of esophageal contraction is lower, and where the aortic arch naturally extrinsically compresses the esophagus. At this location, caustic contents in the medication may come in contact with the esophageal mucosa [24]. One retrospective chart review of patients with pill esophagitis reported that 75% presented with odynophagia [17]. Patients taking medications that are known to carry a higher risk of esophagitis should be told to take their medications with plenty of water and not to lie flat soon after medication administration.
Patients with infectious esophagitis often present with odynophagia. This is especially common in patients with viral esophagitis, such as herpes simplex virus and cytomegalovirus. Among fungal causes of esophagitis, while Candida species are the most common, other infections such as cryptococcosis, histoplasmosis, and aspergillus have also been described [25]. HIV patients may also develop idiopathic esophageal ulcers, which cause significant odynophagia. Patients with infectious esophagitis are often immunosuppressed, and a new diagnosis in the absence of a known immunocompromised status warrants further investigation.
Heartburn and regurgitation
Heartburn and regurgitation are two of the most common gastrointestinal complaints worldwide. Also known as pyrosis, heartburn is considered the classic symptom of gastroesophageal reflux disease (GERD). While defined as a burning sensation in the retrosternal area [26], the term heartburn is frequently misunderstood and is often described as indigestion, sour stomach, and bitter belching [6]. Heartburn typically occurs within 30–60 minutes after eating the largest meal of the day and is often exacerbated by foods such as sugars, chocolate, and fats, which are known to decrease lower esophageal sphincter pressure. Spicy, tomato‐based foods and citrus‐containing foods also worsen heartburn symptoms due to their acidity, irritating esophageal mucosa. Beverages such as alcohol and coffee can also exacerbate heartburn.
Heartburn can be accompanied by the sensation and presence of either a bitter, acidic fluid or salty fluid in the mouth. Regurgitation is the reflux of bitter or salty gastric contents or, at times, the return of food or bilious material from the stomach. Many patients experience heartburn or regurgitation shortly after a late meal, or if they lie down within two hours of eating, both of which can lead to nocturnal symptoms and nocturnal awakenings. Activities such as bending over, straining, lifting heavy objects, and running may all exacerbate heartburn and regurgitation due to an increase in intra‐abdominal pressure. Most heartburn patients report that over‐the‐counter antacids help to reduce symptoms in the short term. However, in patients on antisecretory therapy, regurgitation can occur without coexisting heartburn.
The sensitivity and specificity for the symptom‐based diagnosis of GERD is 67% and 70%, respectively, by gastroenterologists [27]. However, while many heartburn patients do have GERD, other conditions, both esophageal and non‐esophageal, need to be considered. Patients with achalasia, pill‐induced esophagitis, and eosinophilic esophagitis can all present with heartburn and dysphagia. If heartburn worsens with exercise or is associated with other symptoms such as shortness of breath or diaphoresis, then coronary artery disease should be considered. Another newer entity is functional heartburn, defined as (i) burning retrosternal discomfort or pain, (ii) no symptom relief despite antisecretory therapy, (iii) absence of GERD with a negative symptom association, and (iv) absence of a major esophageal motor disorder [28].
Regurgitation needs to be distinguished from rumination syndrome, which is the effortless, repetitive regurgitation of recently ingested food into the mouth, followed by re‐chewing and then re‐swallowing or spitting out [29]. Rumination is often misdiagnosed as GERD or vomiting, which invariably leads to a delay in diagnosis. The pathophysiology of rumination syndrome is not clear, but it usually results from the involuntary contraction of the abdominal musculature, which raises intra‐abdominal pressure, along with simultaneous relaxation of the LES. The evaluation and management of rumination syndrome are discussed in Chapter 4.
Chest Pain
Recurring chest pain that is not due to underlying coronary artery disease is a common presenting symptom of some esophageal diseases. The prevalence in the community has been reported to be 13% and is similar in men and women [30]. Given that the vagal afferents from the esophagus and heart converge prior to their transmission to the brain, it can be challenging to differentiate between cardiac and esophageal chest pain. While concomitant pain with exertion, shortness of breath, and arm or jaw pain point to a cardiac etiology, and while pain upon eating a meal, heartburn, or regurgitation is more suggestive of an esophageal etiology, one cannot make a definitive diagnosis based on these characteristics alone. It is for these reasons that formal evaluation for a cardiac or life‐threatening etiology is mandatory.
Once a cardiac etiology has been excluded, it is then important to assess for an esophageal etiology, as esophageal diseases account for the majority of noncardiac chest pain [31]. The initial patient assessment should include a medication review for any medications known to cause esophageal injury and pill esophagitis. Among esophageal etiologies of chest pain, GERD is the most common cause, as upwards of 50% of noncardiac chest pain patients have abnormal esophageal acid exposure [32, 33]. Patients with esophageal motility disorders such as achalasia or jackhammer esophagus often describe retrosternal chest pain, along with dysphagia.
While assessing a patient for an esophageal etiology, it is also important to consider other noncardiac, non‐esophageal sources of chest pain such as musculoskeletal disorders (costochondritis), psychiatric disorders, and functional chest pain. The evaluation and management of noncardiac chest pain are discussed in Chapter 2.
Globus
Globus is a functional esophageal disorder that is best characterized by the sensation of a lump or tightness in the throat, which is nonpainful, is mostly episodic, often improves with eating and swallowing, and is not associated with dysphagia [34]. The sensation has been reported in up to 46% of healthy individuals [35]. The diagnostic criteria for globus are detailed in Table 1.5 [28]. The diagnosis is made through a compatible clinical history and also by ensuring the absence of a structural lesion, GERD, or major motor disorder. The presence of any alarm symptoms such as weight loss or dysphagia warrants further investigation. While globus is more common in patients with reflux symptoms, a strong relationship between GERD and globus has not been established, and for many patients, globus does not respond well to antireflux therapy [28, 34, 36]. The presence of a gastric inlet patch has been associated with globus, and some studies have shown that endoscopic ablation may improve symptoms [37, 38], but the relationship between an inlet patch and globus is inconsistent. When no obvious etiology is found, the pathophysiology of globus is thought to likely be related to visceral hypersensitivity, as is seen in other functional disorders [28].
Table 1.5 Diagnostic criteria for globus.
| Must include all of the following for the past three months, with symptom onset at least six months before diagnosis, with a frequency of at least once per week:Presence of persistent or intermittent, nonpainful sensation of a lump in the throat, with no structural lesion identifiedOccurrence of the sensation between mealsAbsence of dysphagiaAbsence of a gastric inlet patch in the proximal esophagusAbsence of GERD or EoEAbsence of a major esophageal motor disorder |
The management of globus is not well defined, but patients should be reassured that it is a benign condition. Most patients undergo a limited trial of acid‐suppressive therapy, along with an upper endoscopy to evaluate for a structural lesion, gastric inlet patch, or other mucosal processes. Historically, psychological factors such as anxiety and depression have been evaluated in globus patients, and up to 96% of globus patients