Board Pearls

Drug failure on twice-daily acid suppression is not refractory reflux, it is a reason to work the patient up, and the workup usually turns up something other than reflux. The Lyon Consensus framework, with its acid-exposure cutoffs and symptom-association tests, sorts persistent symptoms into confirmed reflux, borderline, reflux hypersensitivity, and functional heartburn. Antireflux surgery is mat...

The fourth and final Esophageal Motility episode covers the weak-body disorders on a normal IRP: ineffective motility, absent contractility, and scleroderma, then the one diagnosis you are required to distrust, outflow obstruction with an elevated IRP but peristalsis still firing. The weak-body tracings resolve into three different diseases depending on two numbers: what the body is doing and what...

Once achalasia is off the table, a normal IRP sends you into the body of the esophagus, which can only fail two ways: too much or too little. This episode is the too-much side: distal esophageal spasm and hypercontractile jackhammer. Both hinge on a normal IRP, both require symptoms to count, and both must clear secondary causes before earning the word diagnosis.   Topics covered Normal IRP moves...

Episode two of the Peptic Ulcer Disease and H. pylori chapter covers the ulcers that are not driven by H. pylori. It works through NSAID and aspirin injury and its prevention, the sequential exclusion behind refractory and idiopathic ulcers, and the perforation and penetration emergencies that split on whether the leak is free or contained.   Topics covered NSAID and aspirin ulcer mechanism Multip...

H. pylori from biology through eradication and salvage, driven by a handful of load-bearing mechanisms. Urease survival explains both diagnosis and why acid suppression causes false negatives, infection location decides gastric versus duodenal disease, and rising clarithromycin resistance has reshaped first-line therapy toward optimized bismuth quadruple and vonoprazan-based regimens.   Topics cov...

Episode two of two on eosinophilic and infectious esophagitis, covering the infections and direct chemical injuries of the esophagus. One principle links them all: the lining got hurt by something that touched it, and immune status, ulcer shape, and biopsy site tell you the agent. Candida, herpes, CMV, pill esophagitis, and caustic ingestion, each read from contact time, anatomy, and host defenses...

Eosinophilic esophagitis explained from a single mechanism: IL-4 and IL-13 drive eotaxin, eosinophils flood the lining, and chronic inflammation lays down scar. This episode walks the diagnostic criteria, the inflammatory-versus-fibrotic endoscopy split, and the three drugs plus diet, then closes on refractory disease and the dupilumab-plus-dilation combined approach.   Topics covered EoE pathophy...

Esophageal cancer from histology through staging to treatment, built around the one depth boundary that decides endoscopic versus surgical care. Covers adenocarcinoma versus squamous cell, T-stage depth categories, the mucosa-to-submucosa node-risk jump, the fixed staging workup, and the regimens for locally advanced and metastatic disease.   Topics covered Adenocarcinoma vs squamous cell carcinom...

Endoscopic eradication of Barrett esophagus rests on one principle: the segment holds two kinds of tissue that demand two treatments in a fixed order. Resect visible disease first for a staging specimen, then ablate the flat metaplastic field. This episode covers EMR versus ESD, radiofrequency ablation, cryotherapy salvage, and the intensive post-eradication surveillance that recurrence at the jun...

Episode one of the Barrett Esophagus and Esophageal Cancer chapter covers how to diagnose Barrett's, why the metaplasia climbs toward cancer, and how the dysplasia grade sets the surveillance interval. The organizing idea: the worse the cells look, the faster they progress, and that speed dictates how often you scope. American definition, sampling protocol, screening criteria, and grade-based inte...

Acid-suppressing drugs work only when their mechanism and timing line up. This episode explains why proton pump inhibitors heal erosive disease when histamine blockers fade, why wrong meal timing is the top cause of apparent PPI failure, and where vonoprazan changes the game.   Topics covered One pump, three switches: gastrin, histamine, acetylcholine H2 blockers fade as the cell ramps up PPIs are...

GERD is a failure of the antireflux barrier, not acid overproduction. Most patients have a normal resting sphincter, so transient lower esophageal sphincter relaxations are the dominant mechanism, and a sliding hiatal hernia amplifies every failure mode at once. Endoscopy grades the erosive damage, sizes the hernia, and decides treatment intensity, surveillance, and surgical candidacy from one loo...

Achalasia is where the manometry numbers point most often, and every strange feature of the disease falls out of one lesion: loss of the inhibitory nerves that relax the sphincter and time the wave. The sphincter clamps but never releases, the body loses its wave, and what the body does on those failed swallows names the subtype. Subtype picks treatment because it changes what the procedure has to...

Manometry from first principles: every swallow the esophagus has two jobs, the sphincter must open and the body must squeeze in a top-to-bottom wave, and every number the test reports measures one of those two jobs. This episode teaches the order you read them in, sphincter first then body, because that sequence decides which half of the differential you are even in. Master the three numbers here...

The dysphagias the standard scope-then-manometry workup misses: those after fundoplication and bariatric surgery, and those reaching the esophagus from systemic disease. The unifying skill is knowing which history question surfaces the surgical or systemic story the scope report cannot carry.   Topics covered Post-fundoplication dysphagia patterns Post-bariatric surgery dysphagia Scleroderma esoph...

Episode two of the Esophageal Symptoms chapter covers the complaints that aren't classic dysphagia: globus, rumination, supragastric belching, functional chest pain, and painful swallowing. The unifying tell is a reflux-looking patient who fails real acid suppression, which means the problem was never acid. Diagnosis is made from the history and exposures; the test only confirms it.   Topics cover...

This episode reduces the entire dysphagia workup to two bedside questions, where food sticks and what sticks when, and shows why each answer selects its own test. It sorts oropharyngeal from esophageal dysphagia, maps the solids-versus-mixed and tempo patterns onto specific diagnoses, and clarifies why new dysphagia is itself an alarm symptom that mandates a scope regardless of age.   Topics cover...