Professionals have identified several etiologies. Reflux or erosive esophagitis that occurs as a consequence of reflux of gastric contents into the stomach leading to mucosal injury is one of the most common causes of esophagitis. Radiation, infections, local injury caused by medications (pill esophagitis), and eosinophilic esophagitis (EoE) are also other possible etiologies.
The most common symptoms are chest pain, odynophagia, and dysphagia. Patients with EoE can present with food impaction. If the esophagitis is severe and leads to strictures, fistulization, and perforation, patients can present with symptoms related to those.
Diagnosis is usually achieved with endoscopy and biopsies. If the history is very suggestive of medication-induced (pill) esophagitis, endoscopy may not be initially required. Patients with eosinophilic esophagitis will have a characteristic eosinophilic infiltration (> 15 eosinophils per high-power field). Histology can also be helpful in diagnosis 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 intracytoplasmatic inclusions and amphophilic intranuclear inclusions are suggestive of CMV esophagitis.
Patients with eosinophilic esophagitis will have a characteristic eosinophilic infiltration (> 15 eosinophils per high-power field). Histology can also be helpful in diagnosis 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 intracytoplasmatic inclusions and amphophilic intranuclear inclusions are suggestive of CMV esophagitis.
Furthermore, the appearance of the mucosal lesions on endoscopy 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 diffuse, linear, yellow-white plaques adherent to the mucosa. CMV esophagitis is characterized by several large, shallow, superficial ulcerations. HSV esophagitis results in multiple small, deep ulcerations.
Treatment depends on the etiology. If the etiology is acid reflux, use of H2 blockers or proton-pump inhibitors is indicated, along with lifestyle modifications. If the etiology is medication-induced esophagitis, the medication should be stopped if possible or otherwise; the patient should be instructed to take pills with 4 oz of water and remain upright for 30 min after taking the pills. If EoE is the etiology, the treatment will include acid suppression, topical or systemic steroids, dietary modification and endoscopic therapies such as dilations is strictures are present. If etiology is infectious, target therapy is indicated. For C. albicans, esophagitis treatment is with Nystatin or Fluconazole. For HSV esophagitis, treatment is oral or intravenous acyclovir and Foscarnet for those who are non-responders. For CMV esophagitis, treatment is with Gancyclovir intravenously.
There are many causes of esophagitis and healthcare workers in many disciplines will encounter these patients. To avoid delay in diagnosis, a multidisciplinary 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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