{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 1, Ep 2 of 3: Globus, Rumination, and Odynophagia","html":"","width":"100%","height":180,"duration":839,"description":"This episode takes the patients who arrive after a structural and\nreflux workup has already come back clean. Here the history leads and\nthe test only confirms, so the whole skill is recognizing the\nphenotype on the story. PPI failure in someone who looks like GERD on\nthe surface is the alert that the diagnosis is not GERD.\n \nThe case. A young woman regurgitates recognizable food ten to fifteen minutes\nafter nearly every meal. It is effortless, without nausea or retching,\nand she has gained weight on twice-daily PPI. What is the diagnosis,\nwhat test confirms it, and why is more acid suppression the wrong move?\n \nTopics covered\n\nGlobus: the sensation eases or is unchanged by swallowing, the inverse of true dysphagia\nGlobus workup is targeted; ENT exam and reassurance, not a default PPI\nRumination: effortless postprandial regurgitation of recognizable food, no retching\nRumination fingerprint on postprandial HRM-impedance: the abdominal-strain R-wave\nRumination treatment is diaphragmatic breathing, not acid suppression or fundoplication\nSupragastric belching: learned air cycle, gone in sleep, retrained like rumination\nFunctional chest pain: visceral hypersensitivity treated with a neuromodulator, not more PPI\nOdynophagia is mucosal injury until proven otherwise, sorted by exposure before EGD\nPill esophagitis: kissing ulcers at the aortic arch; doxycycline, KCl, bisphosphonates\nInfectious esophagitis by host: Candida plaques, HSV volcano-edge, CMV deep serpiginous\nBiopsy site separates the viruses: HSV from the ulcer edge, CMV from the ulcer base\n\n \nKey decisions\n\nRumination and functional chest pain both defeat escalating PPI because neither lesion is acid: retraining and neuromodulators are the answers\nGlobus with no alarm features (dysphagia, weight loss, hoarseness, neck mass, smoking) gets ENT exam and reassurance, not endoscopy\nPill esophagitis is a history diagnosis: sudden retrosternal odynophagia after a specific tablet taken with little water, kissing ulcers...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}