A 44-year-old man with a long-standing history of heartburn comes to the office due to worsening substernal burning, particularly at night. The discomfort has been less responsive than usual to over-the-counter antacids. The patient also now has significant substernal pain after swallowing food. However, swallowing does not result in coughing, choking, or a sensation of food getting stuck. He has no other chronic medical conditions. Recent HIV testing was negative. The patient takes no other medications. He drinks 2 or 3 beers each evening and smokes a pack of cigarettes daily. BMI is 34 kg/m². Vital signs are within normal limits. Physical examination reveals no abnormalities. The recent worsening of this patient's symptoms is most likely related to which of the following?

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Quizplus · Accepted Answer

11ec160b_3add_5db2_9249_ad8e09238e53_MD0001_00 Gastroesophageal reflux disease (GERD) is caused by the retrograde flow of acidic stomach contents through the lower esophageal sphincter into the esophagus. Common symptoms include burning pain in the retrosternal area (heartburn) and acid regurgitation into the back of the mouth. GERD usually does not cause esophageal mucosal injury, but frequent exposure to highly acidic secretions can overwhelm esophageal mucosal defense mechanisms and result in epithelial damage and complications, such as: Erosive esophagitis with esophageal ulcers - often marked by a worsening of baseline GERD symptoms and the development of odynophagia (painful swallowing). Barrett esophagus - metaplastic columnar epithelium replaces the normal stratified squamous epithelium in the distal esophagus. Most cases are asymptomatic with no change in baseline GERD manifestations. However, Barrett esophagus is a premalignant condition for esophageal adenocarcinoma, which typically presents with dysphagia and weight loss (Choices A and C). Esophageal stricture - typically develops in the setting of a healing esophageal ulcer when collagen fibers contract and cause narrowing of the esophageal lumen. Patients usually present with dysphagia and a sensation of food getting stuck in the esophagus (Choice D). (Choice B) Infectious esophagitis can be caused by a number of agents, including cytomegalovirus, Candida, and herpes simplex virus. However, it occurs most commonly in immunosuppressed patients (eg, AIDS, prolonged steroids). This patient has no evidence of an immunocompromised state (eg, recent HIV testing was negative) and has long-standing GERD, making erosive esophagitis more likely. Educational objective: New-onset odynophagia in the setting of chronic gastroesophageal reflux disease should raise suspicion for erosive esophagitis with esophageal ulcers. Diagnosis is made by upper endoscopy. __________ References: Pathophysiology of gastro-oesophageal reflux disease. (http://www.ncbi.nlm.nih.gov/pubmed/17345925)

A 44-Year-Old Man with a Long-Standing History of Heartburn Comes