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Esophagitis

Last updated: August 20, 2021

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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.

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

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]

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

Approach [3][5][6]

Empiric pharmacotherapy

Initial diagnostics

EGD

Pathology

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

Additional diagnostics (not routinely required)

Clinical features [3]

Etiology

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

Clinical features [2][11]

Diagnostics [2][11][12]

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]

Medication-induced esophagitis [14]

Other substance-induced esophagitis

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

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  11. Herpes simplex esophagitis. http://www.pathologyoutlines.com/topic/esophagusHSV.html. Updated: September 6, 2019. Accessed: March 6, 2020.
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  21. CMV - cytomegalovirus. https://www.pathologyoutlines.com/topic/esophagusCMVesophagitis.html. Updated: September 5, 2019. Accessed: March 5, 2020.