• Oesophagitis: A term covering a broad spectrum of entities that induce inflammatory

changes in the oesophageal mucosa.

• Causes

Gastroesophageal reflux disease (GERD), the most common cause of Oesophagitis.

Refer to above for Gastro-Oesophageal Reflux Disease

• Infectious causes include the following:

Fungal

-Candida species

-Non-candidal fungi (eg, Aspergillus, Histoplasma, Cryptococcus, Blastomyces)

Viral

-Herpes simplex virus (HSV)

-Cytomegalovirus (CMV)

-Varicella-zoster virus (VZV)

-Epstein-Barr virus (EBV)

-Human papilloma virus (HPV)

-Poliovirus

Bacterial species

-Normal flora-in immunocompromised patients: Lactobacillus and B-haemolytic

streptococci can cause oesophagitis

-Mycobacterium tuberculosis

-Mycobacterium avium-intracellular)

Parasitic infections

-Chagas disease

-Trypanosoma cruzi

-Cryptosporidium

-Pneumocystis

-Leishmania Donovan

• Systemic illnesses include the following

 Skin disorders

-Pemphigus Vulgaris

-Bullous pemphigoid

-Erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson syndrome

-Other skin disorders (e.g. lichen planus, psoriasis, acanthosis nigricans,

leukoplakia)

Eosinophilic esophagitis

Inflammatory bowel disease (Crohn disease)

Sarcoidosis

Chronic granulomatous disease

Metastatic cancer

Collagen vascular disease

• Medications

Antibiotics (e.g. tetracycline)

Non-steroidal anti-inflammatory drugs (NSAIDs)

Chemotherapy (e.g. dactinomycin, bleomycin, cytarabine, daunorubicin,

5-fluorouracil, methotrexate, vincristine

• Trauma

Pathophysiology and Epidemiology of Oesophagitis

• The pathophysiology of oesophagitis depends on its etiology.

• Infective oesophagitis is most commonly observed in immunosuppressed hosts but has

also been reported in healthy adults and children.

• A wide range of abnormalities in host defense may predispose an individual to

opportunistic infections, such as neutropenia, impaired chemotaxis, and phagocytosis,

alteration in humoral immunity, and impaired T-cell lymphocyte function.

• Steroids, cytotoxic agents, radiation, and immune modulators can also contribute to

impaired host immune function.

• Disruption of mucosal protective barriers and antibiotics that suppress the normal

bacterial flora may contribute to the invasive ability of commensal organisms.

• The prevalence of symptomatic infection is high in individuals with AIDS, leukemia, and

lymphoma and is low (<5%) in the general medical population.

• In people with HIV, the most significant risk factor is a persistently low CD4 count, but

reports exist of individuals who develop fungal oesophagitis during the seroconversion

phase.

• Patients with systemic diseases (e.g. diabetes mellitus, adrenal dysfunction, alcoholism)

and those of advanced age can be predisposed to infectious oesophagitis because of

altered immune function.

• Illnesses that interfere with oesophageal peristalses, such as achalasia, and oesophageal

neoplasia may contribute to fungal oesophagitis.

• Steroid therapy and other immunosuppressive medications contribute to fungal infection

by suppressing both lymphocytes function and granulocyte function.

• Other medications associated with pill oesophagitis cause injury by local or topical injury.

Epidemiology

• Frequency is unknown

Mortality/Morbidity

• Patients may experience dysphagia, pain, odynophagia, and malnutrition in severe

esophagitis.

• Rarely, life-threatening bleeding occurs and may lead to death.

• Outcomes and survival in these patients is related to the severity of their underlying

systemic illness.

• Race

No racial predilection is observed

• Sex

No sexual predilection is observed

• Age

No age-related differences are reported

Oesophagitis is commonly seen in adults and is uncommon in childhood

Clinical Features of Oesophagitis

History

• A history of immunosuppression, steroid therapy, recent antibiotic use, or systemic illness

supports the diagnosis.

• Although patients may be asymptomatic, typical symptoms include the following

The onset of difficult or painful swallowing (i.e. dysphagia, odynophagia)

Heartburn

Retrosternal discomfort or pain

Nausea, vomiting

Fever, sepsis

Abdominal pain

Epigastric pain

Hematemesis (occasionally)

Anorexia, weight loss (depends on chronicity and severity of underlying illness)

Cough

Physical

• Look for signs of immunosuppression and other underlying diseases

Examine the oral cavity (for thrush or ulcers)

 

Differential Diagnoses, Investigations & Treatment of Oesophagitis

Differential Diagnosis

• Gastroesophageal reflux disease

• Peptic ulcer disease

• Non-ulcer reflux disease

• Pulmonary embolism

• Coronary artery disease

• Angina pectoris

• Pericarditis

• Aortic aneurysm

• Functional dyspepsia

Investigations

Note: Almost all the investigations and drugs for the treatment of oesophagitis are not available

at dispensary and health center levels. Therefore referring patients for these are very

important. The investigations and treatment is outlined below.

• Laboratory Studies

CBC count in patients with neutropenia or who are immunosuppressed.

CD4 count and HIV test in patients with HIV.

• Imaging Studies

Barium studies (Barium swallow) are recommended as the initial imaging study in

patients presenting with dysphagia.

• Procedures

Esophagogastroduodenoscopy (EGD) is diagnostic

Treatment

• Medical Care

• Treatment is directed at the underlying cause and minimizing morbidity.

• Treatment options are as follows

-Candida esophagitis

Topical non-absorbable agents include nystatin and clotrimazole

Oral agents include fluconazole and itraconazole

Parenteral agents include amphotericin B, fluconazole, and flucytosine.

Choice of agent depends on the severity of infection and degree of host defense

impairment.

-HSV oesophagitis

Diagnosis made at endoscopy

Treatment-Acyclovir

-CMV oesophagitis

Ganciclovir (acyclovir analog)

Foscarnet

-Varicella-zoster virus esophagitis

Acyclovir

Famciclovir

-EBV esophagitis:

Acyclovir (may require long-term maintenance to suppress oral hairy leukoplakia)

-Human immunodeficiency virus esophagitis

Corticosteroid therapy, usually for longer than 1 month

Antiretroviral therapy for HIV

-Metastatic cancer esophagitis

Radiation therapy

Palliation with stents

-Medication-related esophagitis (pill esophagitis)

Stop medication

Control of acid reflux may accelerate healing

Patients should take medication with plenty of water while sitting in the upright

position

 

Surgical Care

• Surgical care may be necessary for perforation and fistulas.

Diet

• No particular restrictions are necessary.

• If the patient has odynophagia or is unable to consume calories orally, then gastric

feeding or parenteral feeding may be needed.

Complications

• Stricture formation

• Malnutrition

• Perforation or bleeding (rare)

Prognosis

• The prognosis is good with rapid diagnosis and proper treatment

• Ultimately, prognosis depends on the underlying disease process

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