Clinical Manual for Management of the HIV-Infected ... - myCME.com

Esophageal Problems
Background
Esophageal problems in HIV-infected patients include
difficulty swallowing (dysphagia) or midline retrosternal
pain when swallowing (odynophagia). Pain may be
diffuse throughout the esophagus or localized in specific
areas.
Several conditions may cause esophageal problems.
Of the infectious causes of dysphagia in HIV-infected
patients, Candida is the most common (50-70%). Druginduced
dysphagia, gastroesophageal reflux disease
(GERD), vomiting, and hiatal hernia can also cause
esophagitis. Less commonly, neoplasm or another cause
of stricture may produce symptoms. Neuromuscular
or neurological causes may be seen in patients with
advanced AIDS.
If untreated, esophageal problems may result
in esophageal ulcers, scarring of the esophagus,
dehydration, and weight loss.
S: Subjective
The patient may complain of difficulty swallowing,
a feeling of something being “stuck in the throat,”
retrosternal pain when eating, “hiccups,” indigestion
(“heartburn”), acid reflux, nausea, vomiting, or
abdominal pain.
History
The history should include the following:
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
Medications (prescription and over-the-counter) and
herbal supplements, current and past
Concurrent gastrointestinal (GI) symptoms, such as
abdominal pain or diarrhea
Recent dietary history
Location and characteristics of pain (diffuse or focal)
Oral thrush
Aphthous ulcers
Cytomegalovirus (CMV)
Candida esophagitis
GERD
Hiatal hernia
O: Objective
Section 5—Complaint-Specific Workups | 5–13
Include the following in the physical examination:
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
Measure vital signs (temperature may be elevated
with certain infections, such as CMV, but not
with herpes simplex virus [HSV], candidiasis, or
idiopathic ulcers).
Record weight (and compare with previous weights).
Assess for oral candidiasis, lesions, and masses.
Examine optic fundi to evaluate for CMV retinitis
(in patients with CD4 counts of