Esophagitis refers to inflammation or injury to the esophageal mucosa. There are many causes of esophagitis and essentially the presentation is similar which include retrosternal chest, heartburn, dysphagia or odynophagia.
One of the most common causes is gastroesophageal reflux, which can lead to erosive esophagitis. Other etiologies include radiation, infections, local injury caused by medications, pill esophagitis, and eosinophilic esophagitis (EoE). The most common symptoms in patients with esophagitis are chest pain, odynophagia, and dysphagia. Patients with EoE may present with food impaction. If the esophagitis is severe and leads to strictures, fistulization, and perforation, patients may present with symptoms related to those entities.
Multiple etiologies for esophagitis have been identified such as reflux esophagitis, Medication (Pills) induced esophagitis, infectious , eosinophilic and radiation esophagitis.
Reflux esophagitis histopathology usually not very specific. common findings are dilation of intercellular space and neutrophils and eosinophils infiltration. Eosinophilic infiltration if present in GERD esophagitis can mimic eosinophilic esophagitis however it also responds to treatment with proton pump inhibitors in contrast with eosinophilic esophagitis
Eosinophilic esophagitis histopathology shows intraepithelial eosinophils and usually requires at least 15/HPF eosinophils in at least one biopsy sample to diagnose EoE.
Multinucleated giant cells with ballooning and degeneration of squamous cells with Cowdry type A inclusion is pathognomonic diagnosis finding for HSV esophagitis and Large cells with both intracytoplasmic inclusions and amphophilic intranuclear inclusions are seen in CMV esophagitis.
The most common symptoms and signs are retrosternal chest pain, Heartburns, odynophagia or dysphagia. Patients with EoE can present with food impaction and more often seen in young adults or children with some history of asthma, food allergy or atopy. Reflux esophagitis symptoms may include Globus sensation, regurgitation and sometimes wheezing or chronic cough. History should be included regarding commonly known medicine ingestion which can cause pill-induced esophagitis. History of cancer and radiation therapy can provide a clue regarding radiation esophagitis.
Diagnosis of esophagitis can be made based on history and clinical examination however to differentiate subtypes of esophagitis requires endoscopy and biopsy examination. In suspected acid reflux esophagitis if symptoms are mild to moderate then an endoscopy may not be required and can be reserved if poor or failed response to proton pump inhibitors. Similarly, if the history is very suggestive of medication-induced (pill) esophagitis, endoscopy may not be initially required.
The endoscopic appearance of the mucosal lesions can help with diagnosis. In patients with suspected eosinophilic esophagitis, endoscopy may reveal white exudates or papules, red furrows, corrugated concentric rings, and strictures; but endoscopy may be normal in up to 10% of patients. Endoscopic signs of candidiasis are small, diffuse, linear, yellow-white "cheese-like" plaques adherent to the mucosa. CMV esophagitis is characterized by several large, shallow, superficial ulcerations. HSV esophagitis results in multiple small, deep ulcerations.
Endoscopic biopsy of esophageal lesion histology study can differentiate and confirm different esophagitis etiology. Patients with eosinophilic esophagitis on histology will have a characteristic eosinophilic infiltration (> 15 eosinophils per high-power field). Histology can also be helpful in the diagnosis of infectious etiologies. Multinucleated giant cells with ballooning and degeneration of squamous cells are diagnostic of HSV esophagitis with Cowdry type A inclusions being pathognomonic. Large cells with both intracytoplasmic inclusions and amphophilic intranuclear inclusions are suggestive of CMV esophagitis.
Treatment depends on the etiology but core principles of treatment in addition to etiology specific treatment include acid suppression with PPI or H2 blockers, lifestyle modification, liquid to soft or puree diet to allow adequate time for healing and dietary modification. If the etiology appears to be acid reflux based on history then the use of H2 blockers twice a day or proton-pump inhibitors daily is indicated initially. Patient should also be advised of lifestyle and dietary modifications which include weight loss, elevating the head end of bed (patient with nocturnal symptoms of cough, hoarseness, sore throat), elimination of some dietary triggers such as fatty food, chocolate, carbonated drinks, spicy food, smoking, and alcohol. If the etiology is medication-induced esophagitis, the medication should be stopped if possible and if necessary then should be switched to any other alternatives. The patient should be instructed to take pills with 4 oz of water and remain upright for 30 min after taking the pills. For eosinophilic esophagitis treatment include acid suppression, topical or systemic steroids either topical budesonide or fluticasone and dietary modification if a food allergy is suspected. If etiology is infectious, target therapy is indicated. For C. Albicans, oral fluconazole is the drug of choice. For HSV esophagitis, treatment is oral or intravenous acyclovir and Foscarnet for those who are non-responders. CMV esophagitis is treated with Gancyclovir or Valganciclovir. Treatment of complications like stenosis or stricture may require endoscopic dilation. Addition of topical anesthesia like topical lidocaine (e.g. GI cocktail) and opioids may help in ulcers related pain. NSAIDs must be avoided as it may exacerbate symptoms.
In general, all types of esophagitis can mimic each other as the initial clinical presentation is usually similar and will require further detailed history and further diagnostic test including endoscopy and histopathology examination. Histologically Reflux esophagitis can closely mimic eosinophilic esophagitis. In these cases, usual clinical practice is to prescribe Proton pump inhibitors (PPI) for 8 weeks. Acid reflux esophagitis usually responds well to PPI treatment with a resolution of eosinophilic infiltration but the persistence of clinical symptoms or eosinophilic infiltration on repeat endoscopy confirms EoE. Endoscopy appearance of the esophageal lesion with histology also confirm different types of infectious esophagitis.
Because retrosternal chest pain and dysphagia or odynophagia are common symptoms are shared by many other diseases differential diagnosis is usually broad. Some important differential diagnosis which must be considered is acute coronary syndrome with atypical chest pain, malignancy, peptic ulcer disease, rings and webs, pneumonia, pulmonary embolism, achalasia, and esophageal motility disorder.
Irradiation therapy for treatment of thoracic ,head and neck or abdominopelvic malignancy can cause radiation induced esophageal injury . Treatment
Complication of chronic and untreated esophagitis includes
Gastroenterology service is required in the comprehensive management of esophagitis including diagnosis and treatment of esophagitis related complications. Dietary consultation can be useful in-patient education regarding dietary modification
Lifestyle and dietary modifications are important parts of treatment and further prevention of esophagitis. Patient with Acid reflux esophagitis who are overweight should try for weight loss. Common dietary triggers and habits which include fatty and spicy meals, coffee, carbonated drinks, spicy food, chocolate, alcohol, smoking and not keeping enough time between dinner and bedtime should be avoided. The elevating head end of the bed to 30-45 degree can help with nocturnal symptoms of acid reflux include night cough, sore throat and voice hoarseness. Patient diagnosed with EoE should avoid foods they are allergic to. Maintenance of small meals, clear liquid or soft puree diet during treatment can help with symptoms and accelerate healing time.
There are many causes of esophagitis and healthcare workers in many disciplines will encounter these patients. To avoid delay in diagnosis, an interprofessional approach is necessary. The prognosis for most patients is good with prompt treatment, but ultimately the outcomes depend on the underlying cause. When esophagitis is recurrent, it can lead to anxiety and absenteeism from work because of the need to rule out other more serious causes of chest pain. Untreated esophagitis can lead to stricture formation and malnutrition. Both bleeding and perforation are also relatively common complications. Some patients may aspirate and develop pneumonitis or worsening of asthma. In most patients who do not change their lifestyle, recurrences are common, and thus life long therapy is required. In immunocompromised patients, both candida and herpes can lead to severe pain, dysphagia, and weight loss. Patient education is key when a diagnosis of esophagitis is made. The patient should be told to sleep with the head of bed elevated, avoid lying supine after a meal and lose weight. The patient should also avoid caffeinated beverages, alcohol and discontinue smoking. Finally, the patient should be told to avoid NSAIDS.
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