Clinical Guide > Common Complaints > Esophageal

Esophageal Problems

January 2011

Chapter Contents


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%). Drug-induced dysphagia, gastroesophageal reflux disease (GERD), vomiting, and hiatal hernia also can cause esophagitis. Less commonly, esophageal cancer 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"), retrosternal burning, acid reflux, nausea, vomiting, or abdominal pain.

O: Objective

Include the following in the physical examination:

A: Assessment

Common causes of esophageal problems are as follows:

Less-common causes of esophageal problems include:

P: Plan

Diagnostic Evaluation

Diagnosis often can be made on clinical grounds; in this case, empiric treatment may be initiated (see below). If the diagnosis is unclear, consider endoscopy or radiographic imaging (e.g., computed tomography or barium swallow).

If the patient has dysphagia, odynophagia, unexplained weight loss, GI bleeding, anemia, or atypical symptoms, refer promptly for GI evaluation and endoscopy, or other evaluation as suggested by symptoms.


Determine whether the patient is able to swallow pills before giving oral medications. If pills are not tolerated, the patient may need liquids or troches.

For patients with severe oral or esophageal pain, viscous lidocaine 1% 5-10 mL 2-4 times daily (with swallowing precautions) or Magic Mouthwash (viscous lidocaine 1%, tetracycline, diphenhydramine, and nystatin compounded 1:1:1:1) may be tried.

Other treatments may depend on the underlying cause:

Esophageal conditions that do not resolve with treatment require referral to a GI specialist for diagnostic endoscopy, with biopsy and brushing for histopathology and cultures as appropriate.


It is important that patients maintain adequate caloric intake, preferably with foods and liquids that can be swallowed easily. Nutritional supplements along with soft, bland, high-protein foods are recommended. Refer to a nutritionist as needed.

Potential ARV Interactions

Caution: H2 blockers and PPIs interfere with the absorption of atazanavir and several other PIs. For atazanavir, specific dosing strategies are required, and some combinations are contraindicated. See atazanavir package insert for dosage recommendations.