We reviewed a fictional case of a young man presenting with odynophagia. His medical history was significant for previous treatment for primary syphilis with benzathine penicillin G and presenting with pain with swallowing to your clinic. His CBC was unremarkable other than mild thrombocytopenia for 119. We discussed how odynophagia differs from dysphagia and globus sensation and some of the etiologies that can cause these. We also reviewed an approach to dysphagia and how neuromuscular and structural causes differ in terms of symptoms. Finally, our patient was diagnosed with esophageal candidiasis secondary to HIV infection. We reviewed a basic introduction to HIV and opportunistic infections.
- How do they differ?
One of the terms above, visceral hypersensitivity, refers to having a lower threshold for induction of pain in the presence of normal gastric compliance. This may be related to aberrant central processing of esophageal sensations, and both mechanoreceptor dysfunction and aberrant processing of afferent input in the spinal cord or brain. Patients can have dyspepsia as well as globus sensation.
Globus sensation can also be caused by GERd, abnormal upper esophageal sphincter function, and stress.
2. How do we approach dysphagia?
Peptic strictures can also be seen in patients with progressive dysphagia with solids specifically in the setting of chronic heart burn however they should not have any red flag symptoms (i.e. no weight loss).
In terms of symptoms, when patients have oropharyngeal dysphagia they will often have a predisposing neuromuscular condition, experience choking, drooling, have symptoms above the sternal notch and may have a history of previous surgery or radiation to the head and neck.
Esophageal dysphagia is described as regurgitation, sensation of material getting ‘stuck’ below sternal notch. The symptoms for structural disorders include regular, short duration, rapid progression, solid (but may progress to liquid). Alarm features in general for structural esophageal dysphagia are onset age > 50 years, bleeding, odynophagia, weight loss, and vomiting.
With respect to motility disorders, usually symptoms are with solids and liquids and have a longer duration of each episode. The associations are that they can present with non-cardiac chest pain, diabetes mellitus, or features of connective tissue diseases.
Oropharyngeal dysphagia is often investigated with a video swallowing study (involve Speech and Language Pathology)! Esophageal symptoms – if there is alarm symptoms you should refer for endoscopy. No alarm symptoms and age < 50, symptoms of GERD –> warrants trial of PPI!
The guidelines state that endoscopy is recommended over barium swallow for investigation of esophageal dysphagia (also biopsies can be taken on endoscopy for things like eosinophilic esophagitis). Manometry is recommended over barium swallow for investigation of motility disorders.
In achalasia, you must rule out pseudo-achalasia i.e. obstruction so you do an endoscopy first. On endoscopy, usually you will see puckered gastro-esophageal junction and a dilated fluid filled esophagus as disease progresses. Step 2 is getting a high resolution manometry which is the gold standard. (Barium swallow shows you a ‘bird’s beak esophagus.’
3. Esophageal Candidiasis
The patient in our fictional case with odynophagia was sent for endoscopy. Esophageal candidiasis presents with odynophagia or pain on swallowing. Patients localize their pain to the retrosternal area. Patient with esophagitis often have evidence of oropharyngeal disease (thrush) on exam; however you can have esophageal candidiasis without oral thrush.
Oropharyngeal candidiasis (thrush) can be treated with the following: (reference UpToDate)
- Mild infection:
- Clotrimazole troches (10 mg orally 5 times daily) or
- Miconazole mucoadhesive buccal tablets (50 mg once daily applied to the mucosal surface over the canine fossa); or
- Nystatin suspension or pastilles (400,000 to 600,000 units orally 4 times daily)
- Moderate to severe or unresponsive to topical treatment would be treated with:
- Fluconazole (200 mg orally on day 1 then 100 to 200 mg orally daily)
- Duration usually 7-14 days, but up to 28 days if refractory.
Esophageal candidiasis should never be treated with topical therapy. Treatment is fluconazole (400 mg orally or IV on day 1 then 200 to 400 mg daily) for a duration of 14-21 days. For refractory disease, the duration is extended to 28 days.
HIV serology was also sent on the patient in our fictional case and returned positive. We moved our discussion to a brief introduction of new diagnosis of HIV. (See Part II of morning Report blog post)
- Approach to dysphagia: https://www.aafp.org/afp/2000/0615/p3639.html
- Dysphagia, odynophagia, heartburn: https://sites.ualberta.ca/~loewen/Medicine/GIM%20Residents%20Core%20Reading/DYSPHAGIA,%20GERD,%20BARRETTS%20ESOPHAGUS/dysphagia,%20heartburn%20Slezinger.pdf
- An interesting case of odynophagia: https://www.bmj.com/content/343/bmj.d3137.full
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