Snapshot A 47-year-old man presents to the emergency department complaining of retrosternal pain. The patient states that for the past 2 weeks he has had pain with swallowing and now the pain is almost constant. His medical history is significant for a renal transplant 5 months ago, for which he is on immunosuppressive therapy. Physical examination is unremarkable. An upper endoscopy reveals multiple, discrete, shallow ulcerations of the esophagus. (Herpes simplex virus esophagitis) Introduction Clinical definition inflammation of the esophageal lining Differential esophageal stricture distinguishing factors login to view 2 more bullets can itself be a complication of esophagitis achalasia distinguishing factors login to view 2 more bullets systemic scleroderma distinguishing factors login to view 3 more bullets Etiology Pathogenesis eosinophilic corrosive infectious Candida herpes virus cytomegalovirus (CMV) gastroesophageal reflux disease (GERD) medication-induced Corrosive Esophagitis Corrosive esophagitis pathogenesis ingestion of strongly acidic or basic chemical login to view 6 more bullets demographics 50% of toxic exposures occur in children 5 years or younger risk factors pediatric population suicide attempts Presentation odynophagia retrosternal pain dysphagia drooling hematemesis Studies endoscopy indicated if login to view 3 more bullets contraindicated if login to view 1 more bullet Treatment observation if asymptomatic and does not require endoscopy nasogastric tube or gastrostomy tube if endoscopy reveals extensive circumferential burns prophylactic antibiotics if perforation suspected if there are severe burns use of neutralizing agents, diluting agents, or activated charcoal is not recommended Complications esophageal perforation pathogenesis login to view 1 more bullet presentation login to view 3 more bullets imaging login to view 6 more bullets complications login to view 1 more bullet esophageal stricture formation pathogenesis login to view 1 more bullet risk factors login to view 1 more bullet presentation login to view 1 more bullet studies login to view 5 more bullets treatment login to view 1 more bullet Candida Esophagitis Candida esophagitis pathogenesis most secondary to C. albicans risk factors human immunodeficiency virus (HIV) with advanced immunosuppression (CD4 count < 100/mm3) use of inhaled corticosteroids cancer patients Presentation odynophagia dysphagia may have oral thrush Studies endoscopy indicated especially if no improvement in symptoms after empiric antifungal therapy for 72 hours white or yellowish mucosal plaque-like lesions Treatment azoles (i.e., fluconazole, voriconazole, or posaconazole) for HIV patients can trial before confirmation with endoscopy echinocandins (i.e., caspofungin and micafungin) if hospitalized if refractory to azoles amphotericin B if refractory to azoles and echinocandins Herpes Simplex Virus Esophagitis Herpes simplex virus (HSV) esophagitis risk factors solid organ and bone marrow transplant Presentation odynophagia dysphagia retrosternal chest pain fever may have coexistent oropharyngeal ulcers Studies endoscopy vesicles well-circumscribed and “punched-out” ulcers biopsy multinucleated giant cells with ground-glass nuclei and eosinophilic inclusions Treatment acyclovir Cytomegalovirus Esophagitis Cytomegalovirus (CMV) esophagitis risk factors transplant patients long-term dialysis patients HIV-infected patients long-term steroid treatment Presentation odynophagia fever nausea retrosternal burning pain Studies endoscopy single, large, shallow, and linear ulcer biopsy intranuclear or intracytoplasmic inclusion bodies Treatment ganciclovir foscarnet Eosinophilic Esophagitis Eosinophilic esophagitis demographics men > women average age 20-30s associated conditions atopic dermatitis asthma chronic seasonal allergies Presentation dysphagia to solid food retrosternal chest pain nausea vomiting weight loss may present with history of other atopic conditions Studies endoscopy corrugated mucosa longitudinal mucosal furrows fixed esophageal rings narrowed lumen mucosal fragility biopsy extensive eosinophils infiltrated esophageal mucosa immunoglobulin levels may have mildly elevated serum IgE Treatment dietary modifications if specific allergen is found trial of proton pump inhibitors oral aerosolized steroids (i.e., fluticasone or budesonide) systemic steroids if refractory to aerosolized steroids Complications esophageal strictures Medication-Induced Esophagitis Medication-induced esophagitis demographics women > men average age 40s associated medications antibiotics login to view 1 more bullet aspirin other non-steroidal anti-inflammatory drugs (NSAIDs) bisphosphonates potassium chloride iron risk factors taking pills without water taking pills right before lying down pathogenesis direct irritant effect disruption of cytoprotective barrier Presentation retrosternal pain odynophagia dysphagia hematemesis Studies endoscopy indicated if symptoms are severe or persist > 1 week after discontinuation of suspected medication discrete ulcer with normal surrounding mucosa biopsy to rule out other causes Treatment discontinue culprit medication or switch to liquid formulation if available