Esophagitis is a generic term used to describe inflammation of the esophagus. There are several types based on etiology. These conditions present with pain on swallowing (odynophagia) as food rub against the inflamed esophagus during swallowing of food. The 4 types of esophagitis we will touch on are as follows:
- Reflux Esophagitis (GERD): This is a subtype of GERD in which there is inflammation of the esophagus. Recall that not all GERD will have inflammation or erosion of the esophageal mucosa at the GEJ. Most GERD without erosion have no pain on swallowing especially if treated promptly
- Infective Esophagitis: This is inflammation of the esophagus due to infection. These are most commonly seen in immune compromised patients like patients with HIV. The most common culprit that cause infectie esophagitis are Herpes simplex virus type 1 (HSV-1), Cytomegalovirus (CMV), Candidiasis especially in diabetics.
- Eosinophilic Esophagitis : this are commonly seen in patient with a history of allergy with eosinophilia, neutrophils and elongation of lamina propria papillae. Allergy → Dysphagia (strictures) → Heart burn → usually unresponsive to GERD Treatment.
- Drugs-induced Esophagitis: This is common in patient taking medication that can damage the mucosal tissue. The most common medications that can cause esophagitis include cancer treatment drugs, tetracycline, Bisphosphonates, potassium chloride among others.
Symptoms of Esophagitis:
Infective and Drug induced esophagitis cause odynophagia in most cases. In erosive esophagitis, usually odynophagia (pain on swallowing) is present if there is esophageal ulcer
Diagnosis and Management of different Esophagitis:
The type of esophagitis can be diagnosed and differentiated with upper endoscopy.
This is seen in AIDS patients; likely due to Candida infection in 90% of the time especially if the patient is diabetic. Other infection cause include CMV, Herpes simplex virus as we have mentioned above.
Do not need oral thrush to diagnosis, can have esophagitis without oral thrush
Treatment of Infective esophagitis: The treatment depends if the patient is HIV Positive with CD 4 < 100: In patient with HIV positive, the following are the management for esophagitis suspected before upper endoscopy.
- Empirical Fluconazole (Diagnosis and Therapeutic) (no need upper endoscopy)
- If give Fluconazole no response → do upper endoscopy.
- If upper endoscopy Confirm and know fluconazole has no use, then give Amphotericin IV.
- PO Nyastatin is for oral thrush only; not used for esophagitis
In HIV Negative patients: upper endoscopy is done to evaluate the cause of symptoms.
Reflux/erosive esophagitis (GERD):
GERD is treated with PPI as mentioned in other section. See GERD
Drug Induced (Pill Esophagitis)
Potassium chloride, Bisphosphonate (Alendronate), Doxycycline, NSAIDS, FeSO4, Quinidine are all possible medications that can cause pill esophagitis.
Pathogenesis: Direct effect on esophageal mucosa like (tetracyclin acidic effect, osmotic injury via KCl, NSAID stop protection,)
Clinical Presentation: odynophagia (pain of swallow only) and retrosternal pain are present on swallowing. This is unlike Diffuse spasm (random intermittent chest pain and dysphagia instead of only during swallowing). The point is that odynophagia can happen with diffuse spasm but does not have to. Whereas pill esophagitis are almost always associated with swallowing pain.
Diagnosis of pill esophagitis: Usually made by clinical diagnosis but can be confirmed with upper endoscopy (show ulcers with normal appearing surrounding mucosa)
Differential diagnosis – Candida (usually have oral thrush though not needed, and in HIV patient with upper endoscopy with white plaques in esophagus; HSV (vesicles and round/ovoid ulcers; CMV (large linear ulcers are present instead)
Treatment: The main stay treatment for pill esophagitis is drink more water after taking the pill and remain upright for at least 30 min after pill.
The cause of eosinophilic esophagitis is unknown.
Clinical Presentations: Symtoms include – Dysphagia, Vomiting, regurgitation/heart burn, main thing with increased Eosinophil >15/HPF. Usually upper endoscopy will see Schatzki Rings; associated with allergens (history of asthma, allergic disease). Characterized by heart burn without response to medication for GERD.
Diagnosis: upper endoscopy will show multiple concentric rings. Most accurate diagnostic test is upper endoscopy with biopsy finding eosinophils. Manometry show esophageal hypercontractility.
Treatment: Best initial treatment is PPI and remove allergenic food. Most effective treatment is swallowing steroid inhalers (Budesonide).