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 trouble with swallowing solids only strictures observed on endoscopy can itself be a complication of esophagitis achalasia distinguishing factors dilated esophagus that terminates in “bird-beak” narrowing on barium esophagram incomplete lower esophageal sphincter relaxation on esophageal manometry systemic scleroderma distinguishing factors progressive dysphagia to both solids and liquids evidence of other symptoms of systemic scleroderma (i.e., skin thickening) positive serologic tests (i.e., antitopoisomerase) 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 alkali (usually pH 11.5-12.5) i.e., lye or batteries causes liquefaction necrosis acids (usually pH < 2) i.e., hydrochloric acid causes coagulation necrosis 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 symptomatic evidence of oral burns ingested substance is very caustic contraindicated if respiratory compromise 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 especially within 10 days during which granulation tissue formation causes weakening of the esophageal wall presentation respiratory distress (i.e., stridor, hoarseness, nasal flaring, or wheezing) persistent severe retrosternal or back pain fever imaging chest radiograph indicated if presenting with respiratory symptoms to assess for complications of ingestion pneumomediastinum widened mediastinum subcutaneous emphysema in neck complications can lead to mediastinitis or development of a tracheoesophageal fistula esophageal stricture formation pathogenesis usually around 3 weeks as fibrogenesis occurs risk factors more severe or circumferential burns presentation progressive dysphagia studies barium contrast indicated 2-3 weeks post-chemical ingestion or sooner if progressive dysphagia develops contraindicated if perforation suspected water-soluble contrast agents can be used instead treatment esophageal dilation 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 tetracyclines, doxycycline, and clindamycin 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