Achalasia Hallmark
Impaired relaxation of LES + absent peristalsis due to degeneration of myenteric (Auerbach) plexus; 'bird's beak' tapering on barium swallow.
Barrett Esophagus
Intestinal metaplasia (stratified squamous to non-ciliated columnar epithelium with goblet cells) from chronic acid exposure; risk of esophageal adenocarcinoma.
PUD: Gastric vs. Duodenal
Gastric ulcers: pain WORSENS with meals; risk of malignancy; biopsy required. Duodenal ulcers: pain IMPROVES with meals; overwhelmingly benign; 95% H. pylori.
H. pylori Quadruple Therapy
Bismuth subsalicylate + Metronidazole + Tetracycline + PPI for 14 days; confirm eradication with urea breath test or stool antigen at 4 weeks.
Esophageal Motility & Mucosal Pathology
| Condition | Pathophysiology | Clinical Presentation & Barium Swallow | Definitive Diagnosis & Therapy |
|---|---|---|---|
| Achalasia | Loss of inhibitory ganglion cells (VIP / NO) in Auerbach (myenteric) plexus | Dysphagia to both solids and liquids from onset; regurgitation; barium shows 'bird's beak' deformity | High-resolution esophageal manometry (incomplete LES relaxation); Pneumatic dilation or laparoscopic Heller myotomy |
| Diffuse Esophageal Spasm (DES) | Uncoordinated, simultaneous contractions of the distal esophageal smooth muscle | Severe retrosternal chest pain mimicking angina, dysphagia to hot and cold liquids; 'corkscrew' esophagus | Esophageal manometry shows simultaneous non-peristaltic contractions; Calcium channel blockers, nitrates, or botox |
| Mallory-Weiss Syndrome | Superficial longitudinal mucosal lacerations at gastroesophageal junction | Painless hematemesis following forceful, repetitive vomiting/retching (frequently after alcohol binge) | Upper endoscopy (EGD); usually self-limiting, thermal coagulation or hemoclips for persistent bleeding |
| Boerhaave Syndrome | Transmural full-thickness rupture of the distal esophagus | Excruciating retrosternal chest pain, dyspnea, subcutaneous emphysema (Hamman crunch) following retching | Gastrografin contrast esophagram (NOT barium; water-soluble prevents mediastinitis); emergent surgical repair |
OMM Board Correlate: Upper GI Autonomics & Celiac Ganglion
- Stomach & Esophagus Innervation: Sympathetic preganglionics originate from T5–T9 and synapse in the celiac ganglion. Parasympathetic supply arises from the vagus nerve (CN X).
- Chapman Points for Stomach: Anterior point for stomach acidity is in the 5th left intercostal space midclavicular; peristalsis point in the 6th left intercostal space. Posterior points between T5–T6 and T6–T7 on the left.
- Celiac Ganglion Release: Deep inhibitory myofascial pressure applied 2 inches superior to the umbilicus normalizes sympathetic tone and improves mucosal blood flow.
Board Traps & Common Distractors
- In suspected Boerhaave syndrome (esophageal rupture), NEVER use barium contrast; barium produces severe, irreversible, potentially fatal chemical mediastinitis. Always use water-soluble Gastrografin.
- All gastric ulcers require repeat endoscopy with biopsy at 6 to 8 weeks to document complete healing and definitively rule out underlying gastric adenocarcinoma.
- Refractory peptic ulcer disease in the distal duodenum or jejunum with secretory diarrhea indicates Zollinger-Ellison Syndrome (gastrinoma in gastrinoma triangle); check fasting serum gastrin followed by secretin stimulation test.