Last updated: September 15, 2023

Summarytoggle arrow icon

Esophagitis is the inflammation of the esophageal mucosa secondary to direct mucosal injury (e.g., gastroesophageal reflux or GERD, substance-induced esophagitis) or to an inflammatory process (e.g., eosinophilic esophagitis). It can also occur secondary to local infection (e.g., esophageal candidiasis, HSV esophagitis, CMV esophagitis), especially in immunosuppressed individuals. The typical manifestation of esophagitis is retrosternal pain (heartburn). Associated features such as regurgitation, odynophagia, or dysphagia may provide clues to the underlying etiology. Coronary artery disease (CAD) may mimic the retrosternal symptoms of esophagitis and should be ruled out if suspected (e.g., chest pain on exertion, presence of risk factors for CAD). Empiric pharmacotherapy with a trial of proton pump inhibitors (PPIs) is recommended in patients with typical features of GERD. Inadequate response to empiric therapy or atypical features at presentation (e.g., significant dysphagia, odynophagia, fever), risk factors for esophageal cancer, or red flags for dyspepsia should prompt an esophagogastroduodenoscopy (EGD) to directly visualize the esophageal mucosa and obtain biopsies from areas of mucosal abnormalities. Further diagnostics (e.g., esophageal pH monitoring, high-resolution esophageal manometry) should be considered if EGD is inconclusive. Specific management depends on the underlying cause and includes PPIs for GERD, PPIs, dietary restriction and topical steroids for eosinophilic esophagitis, and systemic antifungal or antiviral therapy for infectious esophagitis. Complications of prolonged or severe esophagitis include Barrett esophagus, esophageal strictures, hematemesis, and aspiration.

Definitiontoggle arrow icon

Etiologytoggle arrow icon

Etiologies of esophagitis [1][3]
Mechanism Possible causes
Mucosal injury
Specific infiltrates

The most common cause of esophagitis is GERD, in which gastric acid refluxes into the esophagus and results in direct mucosal injury and subsequent inflammation. [1]

Clinical featurestoggle arrow icon

Reference:s [3][4][5]

Managementtoggle arrow icon

Approach [3][5][6]

Empiric pharmacotherapy

Initial diagnostics



Obtaining biopsies from esophageal mucosa that appears normal on EGD is not routinely recommended. [8]

Additional diagnostics (not routinely required)

Infectious esophagitistoggle arrow icon

Clinical features [3]


  • Fungal: Candida spp. (most common)
  • Viral: CMV, HSV (HSV-1)
  • Uncommon: bacterial esophagitis , parasitic esophagitis

Infectious esophagitis is most commonly seen in patients with immunosuppression (resulting from, e.g., HIV, malignancies, transplantation, dialysis). A diagnosis of infectious esophagitis in patients with no known comorbidities should prompt studies for immunosuppression.

Diagnostics and treatment

Diagnostics and treatment of infectious esophagitis [3][9]
Esophageal candidiasis [10] Herpes esophagitis (mainly HSV-1) CMV esophagitis
Diagnostics Endoscopic findings
  • White or yellowish adherent plaques (pseudomembranes)
Histopathologic findings
Treatment General measures
  • Consider inpatient treatment for patients with severe odynophagia.
  • Optimize nutrition and hydration.
  • Pain management
  • Consult gastroenterology and infectious disease specialists as needed.
  • In treatment-naive patients with AIDS, evaluate the need to initiate antiretroviral therapy in consultation with infectious disease specialists.
Specific treatment
  • Any of the following regimens for a total 21–42 days or until symptoms resolve completely:

In patients with AIDS with CD4 counts below 200/mcL, coexisting fungal and viral infections are possible. Consider extended testing and double therapy for refractory cases.

Eosinophilic esophagitistoggle arrow icon

Epidemiology [2]

Clinical features [2][11]

Diagnostics [2][11][12]

Diagnosis requires symptoms of esophageal dysfunction and histopathologic confirmation of an eosinophil-mediated inflammation on esophageal biopsy.

  • Endoscopic findings
    • Circumferential mucosal lesions (e.g., rings, corrugations), with possible esophageal trachealization (presence of multiple rings in the esophagus, which results in a furrowed or corrugated appearance similar to the trachea)
    • Longitudinal furrows
    • Diffuse narrowing or isolated strictures
  • Histopathologic findings [2]

Treatment [12][13]

∼ 50% of patients with eosinophilic esophagitis do not respond to acid suppression therapy.

Long-term maintenance therapy (dietary elimination and/or pharmacological therapy) is often required to maintain remission. [12][13]

Substance-induced esophagitistoggle arrow icon

Medication-induced esophagitis [14]

Other substance-induced esophagitis

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Odze RD, Goldblum JR. Surgical Pathology of the GI Tract, Liver, Biliary Tract, and Pancreas. Elsevier Health Sciences ; 2009
  2. Kumar S, Choi SS, Gupta SK. Eosinophilic esophagitis: current status and future directions. Pediatr Res. 2020; 88 (3): p.345-347.doi: 10.1038/s41390-020-0770-4 . | Open in Read by QxMD
  3. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018
  4. Management of Gastroesophageal Reflux Disease. Updated: January 1, 2003. Accessed: January 17, 2020.
  5. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013; 108 (3): p.308-328.doi: 10.1038/ajg.2012.444 . | Open in Read by QxMD
  6. Gyawali CP, Carlson DA, Chen JW, Patel A, Wong RJ, Yadlapati RH. ACG Clinical Guidelines: Clinical Use of Esophageal Physiologic Testing. The American Journal of Gastroenterology. 2020; 115 (9): p.1412-1428.doi: 10.14309/ajg.0000000000000734 . | Open in Read by QxMD
  7. Guntipalli P, Chason R, Elliott A, Rockey DC. Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome. Dig Dis Sci. 2014; 59 (12): p.2997-3003.doi: 10.1007/s10620-014-3258-4 . | Open in Read by QxMD
  8. Rosołowski M, Kierzkiewicz M. Etiology, diagnosis and treatment of infectious esophagitis. Gastroenterology Review. 2013; 6: p.333-337.doi: 10.5114/pg.2013.39914 . | Open in Read by QxMD
  9. Mohamed AA, Lu X, Mounmin FA. Diagnosis and Treatment of Esophageal Candidiasis: Current Updates. Canadian Journal of Gastroenterology and Hepatology. 2019; 2019: p.1-6.doi: 10.1155/2019/3585136 . | Open in Read by QxMD
  10. Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol. 2017; 112 (7): p.988-1013.doi: 10.1038/ajg.2017.154 . | Open in Read by QxMD
  11. Bux J. Transfusion-related acute lung injury (TRALI): a serious adverse event of blood transfusion. Vox Sang. 2005.doi: 10.1111/j.1423-0410.2005.00648.x . | Open in Read by QxMD
  12. Zografos GN, Georgiadou D, Thomas D, Kaltsas G, Digalakis M. Drug-induced esophagitis. Diseases of the Esophagus. 2009; 22 (8): p.633-637.doi: 10.1111/j.1442-2050.2009.00972.x . | Open in Read by QxMD
  13. Koutlas NT, Eluri S, Rusin S, et al. Impact of smoking, alcohol consumption, and NSAID use on risk for and phenotypes of eosinophilic esophagitis. Diseases of the Esophagus. 2017; 31 (1).doi: 10.1093/dote/dox111 . | Open in Read by QxMD
  14. Moawad FJ, Cheng E, Schoepfer A, et al. Eosinophilic esophagitis: current perspectives from diagnosis to management. Ann N Y Acad Sci. 2016; 1380 (1): p.204-217.doi: 10.1111/nyas.13164 . | Open in Read by QxMD
  15. Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA. ACG Clinical Guideline: Evidenced Based Approach to the Diagnosis and Management of Esophageal Eosinophilia and Eosinophilic Esophagitis (EoE). Am J Gastroenterol. 2013; 108 (5): p.679-692.doi: 10.1038/ajg.2013.71 . | Open in Read by QxMD
  16. Hirano I, Chan ES, Rank MA, et al. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Gastroenterology. 2020; 158 (6): p.1776-1786.doi: 10.1053/j.gastro.2020.02.038 . | Open in Read by QxMD
  17. CMV - cytomegalovirus. Updated: September 5, 2019. Accessed: March 5, 2020.
  18. Candida. Updated: February 5, 2020. Accessed: March 5, 2020.
  19. Herpes simplex esophagitis. Updated: September 6, 2019. Accessed: March 6, 2020.
  20. Pill induced esophagitis. Updated: February 12, 2019. Accessed: March 6, 2020.
  21. Eosinophilic esophagitis. Updated: December 5, 2019. Accessed: March 6, 2020.

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer