Esophageal Disorders

A 47-year-old man presents to your office complaining that for the past 6 months, food "feels like it gets stuck in my chest." The patient points to his midsternum as he describes the symptoms. He denies having trouble swallowing liquids, and he denies having odynophagia. His symptoms are sporadic and have not gotten worse recently. His weight is stable. On examination, the patient appears healthy. Results of laboratory studies are unremarkable.   On the basis of medical history, which of the following is the most likely cause of this patient's dysphagia?

Three weeks ago, you diagnosed a 66-year-old male patient as having dysphagia of new onset. Today, the patient returns to clinic for a follow-up visit to receive the results of diagnostic testing. The results of a barium esophagogram are consistent with achalasia, and esophageal manometry reveals aperistalsis. The patient describes his symptoms as being moderate; he can tolerate food as long as he eats very slowly and does not lie down for at least 3 hours after meals. He rarely experiences symptoms when drinking liquids. He has lost 6 lb over the past 3 months.   Which of the following is the most appropriate step to take next in the management of this patient?

A 32-year-old woman with dysphagia for solid food presents to clinic for a follow-up visit. Upper endoscopy revealed multiple esophageal rings and eosinophilia but no strictures. The patient continues to complain of heartburn and food "sticking." You recommend dilation with bougienage, a proton pump inhibitor (PPI), and corticosteroids as initial therapy.   Which of the following family histories is most consistent with the diagnosis of eosinophilic esophagitis (EOE) in this patient?

A 42-year-old man presents to clinic complaining of frequent regurgitation of undigested food, coughing whenever he tries to swallow, and halitosis. His wife has started to complain about his bad breath, and he wants to know what is wrong. He reports brushing his teeth three to four times daily, with no improvement in the smell of his breath.   Which of the following is the best step to take next in the evaluation of this patient?

A 37-year-old woman presents to clinic for further evaluation of chronic cough. She is an otherwise healthy nonsmoker. Her only medication is a PPI, which you prescribed empirically 1 month ago. Her symptoms have not resolved despite trials of inhaled steroids, an antihistamine, bronchodilators, and her current PPI. She denies experiencing any weight loss, dysphagia, or chest pain. On examination, the patient appears well-nourished. Her sinuses are nontender, and the oropharynx is clear. The pulmonary examination is normal. A chest x-ray is within normal limits. You suspect that her symptoms are related to GERD.   Which of the following treatments is recommended for this patient?