Diagnosis and Management of Common Esophageal Disorders

1.0 Initial Patient Assessment and Triage

The initial triage of a patient presenting with esophageal symptoms is a critical determinant of clinical outcomes. A systematic approach, predicated on recognizing distinct symptom patterns and alarm features, is essential for directing the urgency and nature of subsequent investigations. This initial assessment allows for the rapid identification of high-risk scenarios, distinguishing between patients who require immediate intervention and those who can be managed on an outpatient basis.

Symptom-Based Triggers for Suspecting Esophagitis

 | Presenting Symptom/Scenario | Associated Differential Diagnosis
 | Odynophagia (Painful Swallowing) | Infectious Esophagitis (Candida, HSV, CMV), Pill-Induced Injury, Severe Reflux Ulcer
| Dysphagia (Difficulty Swallowing) | Eosinophilic Esophagitis (EoE), Peptic Stricture, Schatzki Ring, Malignancy, Motility Disorder
| Chest Pain / Heartburn | Erosive Esophagitis (GERD), Eosinophilic Esophagitis (EoE)
| Food Impaction | Eosinophilic Esophagitis (EoE) until proven otherwise
| Immunosuppression (e.g., HIV) | Infectious Esophagitis, with Candida being the most common
| Recent New Medication Use | Pill-Induced Esophagitis (Doxycycline, bisphosphonates, KCl, NSAIDs, tetracyclines, clindamycin)

Alarm Features Mandating Expedited Endoscopy

The presence of one or more of the following alarm features warrants an expedited esophagogastroduodenoscopy (EGD) to rule out underlying malignancy or other serious pathology:

• Unintentional weight loss
• Gastrointestinal bleed (melena)
• Anemia
• Persistent vomiting
• Progressive dysphagia
• Age ≥50–60 years

Urgency of Endoscopic Intervention

The clinical presentation dictates the necessary timeline for endoscopic evaluation.

• Urgent EGD (Immediate/within 24h)
   
  • Food impaction, particularly if the patient is unable to manage secretions.
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  • Suspected airway compromise or aspiration risk.
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  • Active or suspected significant upper gastrointestinal bleeding.
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• Expedited Outpatient EGD
   
  • Presence of any alarm features (e.g., weight loss, anemia, progressive dysphagia).
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  • Severe odynophagia in an immunocompromised patient who fails to improve after 48-72 hours of empiric therapy.
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This structured initial assessment ensures patient safety and directs resources appropriately, leading directly to the next critical step: the endoscopic evaluation.

2.0 Standardized Endoscopic Evaluation Protocol

Esophagogastroduodenoscopy (EGD) serves as the cornerstone for the diagnosis, and often the treatment, of most esophageal disorders. A standardized protocol for performing and documenting the procedure is essential for ensuring diagnostic accuracy, facilitating effective communication among providers, and enabling appropriate risk stratification and long-term management planning.

Core EGD Procedures and Documentation

1. Landmark Identification: Accurate identification and documentation of key anatomical landmarks are fundamental to any diagnostic EGD.
    
   • Gastroesophageal Junction (GEJ): Defined as the proximal margin of the gastric folds.
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   • Squamocolumnar Junction (Z-line): The visible transition point where the pale, glossy squamous epithelium of the esophagus meets the reddish, columnar mucosa of the stomach.
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   • Diaphragmatic Hiatus: The point of luminal narrowing caused by the crural diaphragm.
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5. Standardized Injury Classification: The severity of mucosal injury must be graded using validated systems to guide therapy and follow-up. The Los Angeles (LA) Classification is used for erosive esophagitis, while the Prague C&M Criteria are used for Barrett's Esophagus. These are detailed in their respective sections below.
6. Biopsy Strategy: A targeted biopsy strategy is crucial for histologic diagnosis, as endoscopic appearance alone is often insufficient.

• Suspected Eosinophilic Esophagitis (EoE): Obtain at least six biopsies from a minimum of two levels (proximal and distal esophagus). Target any visible furrows, rings, or exudates, but also biopsy normal-appearing mucosa.
• Suspected Infectious Esophagitis:
   
  • Candida: White plaques can be brushed or biopsied.
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  • Herpes Simplex Virus (HSV): Biopsy the edge of punched-out or "volcano" ulcers.
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  • Cytomegalovirus (CMV): Biopsy the base of large, linear distal ulcers.
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• Suspected Barrett's Esophagus (BE): Follow the Seattle protocol, taking 4-quadrant biopsies every 2 cm (or every 1 cm if there is a history of dysplasia). Any visible lesions should be targeted first, preferably with Endoscopic Mucosal Resection (EMR) for diagnosis and staging.

Indications for EGD

The indications for performing an EGD can be broadly categorized as diagnostic or therapeutic.

• Diagnostic Indications
   
  • Evaluation of alarm symptoms (dysphagia, odynophagia, weight loss, bleeding, anemia).
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  • Screening for Barrett's Esophagus in high-risk patients (e.g., male, age >50, central obesity, smoker, chronic GERD).
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  • Surveillance of known Barrett's Esophagus.
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  • Evaluation of suspected esophagitis (reflux, eosinophilic, infectious).
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  • Investigation of iron deficiency anemia after a non-diagnostic colonoscopy.
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• Therapeutic Indications
   
  • Removal of an impacted food bolus or foreign body.
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  • Dilation of benign esophageal strictures or rings.
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  • Hemostasis for upper gastrointestinal bleeding.
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  • Endoscopic ablation or resection of dysplastic Barrett's Esophagus.
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Once a diagnosis is established or suspected during the EGD, management is tailored to the specific disorder identified.

3.0 Management of Specific Esophageal Disorders

3.1 Gastroesophageal Reflux Disease (GERD) and Erosive Esophagitis

Gastroesophageal reflux disease is a primary driver of esophageal pathology, leading to mucosal inflammation and injury. The Los Angeles (LA) classification is the global standard for grading the severity of erosive esophagitis, which directly informs the intensity of initial therapy and the need for follow-up endoscopy.

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