Updated: 12/11/2021

Esophagitis

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  • 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

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