AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Esophagitis is a common medical condition usually caused by gastroesophageal reflux. Less frequent causes of esophagitis include infectious esophagitis (in patients who are immunocompromised), radiation esophagitis, and esophagitis from direct erosive effects of ingested medication or corrosive agents.

Pathophysiology

Reflux esophagitis develops when gastric contents are passively regurgitated into the esophagus. Reflux happens commonly and does not cause major harm because natural peristalsis of the esophagus clears the refluxate back to the stomach. In others, where acid reflux from the stomach is persistent, the result is damage to the esophagus causing symptoms and macroscopic changes. Gastric acid, pepsin, and bile irritate the squamous epithelium, leading to inflammation, erosion, and ulceration of the esophageal mucosa.

Frequency

United States

Esophageal reflux symptoms occur monthly in 33-44% of the general population; up to 7-10% of people have daily symptoms.

International

Symptoms of reflux are up to an order of magnitude higher than the prevalence of esophagitis. In the United Kingdom, patients presenting to a general practitioner with symptoms of reflux esophagitis show rates in the 40-65% range. However, a retrospective review of the results of more than 8000 diagnostic endoscopies in Hampshire showed that gastroesophageal reflux disease (GERD) accounted for 23% of all upper gastrointestinal conditions. A review of the Swedish National Register estimated the prevalence of esophagitis (diagnosed by endoscopy) to be less than 5% in the 55-year-old group. Other reports have estimated the prevalence to be on the order of 2%. 

Mortality/Morbidity

Minimal morbidity and mortality result from mild symptoms of esophagitis. Pain from moderate-to-severe symptoms may produce anxiety and lost work and may lead to medical evaluations for more serious causes of pain. Serious GI complications of esophagitis include esophageal strictures, Barrett esophagus, and adenocarcinoma. Aspiration of gastric contents is a potentially serious respiratory complication that occurs more often in children. It may be associated with bronchospasm, pneumonitis, and apnea.

Race

No race predilection has been observed.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• The most common complaint in patients with esophagitis is heartburn (dyspepsia), a burning sensation in the mid chest caused by contact of stomach acid with inflamed esophageal mucosa. Symptoms often are maximal while the person is supine, bending over, wearing tight clothing, or has eaten a large meal.
• Water brash is a bitter taste of refluxed gastric contents often associated with heartburn.
• Other common symptoms of esophagitis include upper abdominal discomfort, nausea, bloating, and fullness. Less common symptoms of esophagitis include dysphagia, odynophagia, cough, hoarseness, wheezing, and hematemesis.
• The patient may experience chest pain indistinguishable from that of coronary artery disease. Pain is often midsternal with radiation to the neck or arm and may be associated with shortness of breath and diaphoresis. Chest pain may be relieved with nitrates if esophageal spasm is involved, further confounding diagnostic evaluation.
• Infants with gastroesophageal reflux are at greater risk of aspiration. Symptoms include weight loss, regurgitation, excessive crying, backache, respiratory distress, and apnea.

Physical

• The physical examination usually is not helpful in confirming the diagnosis of uncomplicated esophagitis. However, the examination may reveal other potential sources of chest or abdominal pain.
• Perform a rectal examination to identify the presence of occult bleeding.

Causes

• Factors or conditions that may increase a person's risk of developing reflux esophagitis include the following:
• • Pregnancy
  • Obesity
  • Scleroderma
  • Smoking
  • Alcohol, coffee, chocolate, fatty or spicy foods
  • Certain medications (eg, beta-blockers, nonsteroidal anti-inflammatory drugs [NSAIDs], theophylline, nitrates, alendronate, calcium channel blockers)
  • Mental retardation requiring institutionalization
  • Spinal cord injury
  • Immunocompromise
  • Radiation therapy for chest tumors
  • Pill esophagitis, thought to be secondary to chemical irritation of esophageal mucosa from certain medications (eg, iron, potassium, quinidine, aspirin, steroids, tetracyclines, NSAIDs), especially when swallowed with too little fluid

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Laboratory tests are usually unhelpful unless complications are present (eg, upper GI hemorrhage). Bleeding, a potentially serious complication of esophagitis, may be excluded upon physical examination with stool guaiac.
• ECG and troponin or other cardiac markers are needed when acute coronary syndrome is in the differential diagnosis.

Imaging Studies

• Routine radiography is not indicated unless complications (eg, perforation, obstruction, bleeding) are suspected.
• Perform a double-contrast esophageal barium study as a first-line test if dysphagia is a primary complaint. A double-contrast esophageal barium study is useful in structural complications such as strictures and tumors.

Other Tests

• Direct endoscopy allows for the visualization and the biopsy of esophageal mucosa. Endoscopy is a useful procedure in evaluating the degree of mucosal damage and is indicated in patients with hematemesis, heme-positive stools, or suspected esophageal obstruction.
• Endoscopy may be indicated on an emergency basis in cases of upper GI hemorrhage, obstruction, or perforation.
• Endoscopy is indicated in patients older than 50 years with new onset of symptoms, in those with features suggesting more serious disease (eg, abdominal mass, anemia, vomiting, dysphagia), and in patients in whom repeated trials of medical therapy have failed.

TREATMENT

Section 6 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Prehospital Care

• No specific prehospital treatment for esophagitis exists. Care is directed toward complications (eg, bleeding, perforation) that require hemodynamic stabilization.
• Chest pain of esophageal origin cannot be differentiated accurately from chest pain associated with coronary artery disease. Therefore, prehospital protocols should be followed for management of chest pain potentially caused by coronary artery disease.
• Oxygen is generally indicated when the cause of the pain is uncertain.

Emergency Department Care

• Treatment of esophagitis is generally not indicated in an ED setting unless complication, such as bleeding, obstruction, dehydration, or perforation, occurs.

Consultations

• Patients with moderate-to-severe bleeding, perforation, or suspected obstruction should consult a gastroenterologist.

MEDICATION

Section 7 of 11  

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• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Treatment goals include pain relief, decreased acid production, decreased acid reflux, and protection of the esophageal mucosa. Multiple pharmacologic agents are available, including histamine-2 receptor antagonists, proton pump inhibitors, gastroprokinetic agents, and protective agents.

Drug Category: Histamine-2 receptor antagonists

These agents decrease gastric acid production by blocking histamine-2 receptors in gastric cells. Some authorities recommend using larger doses than those used for peptic ulcer disease.

Drug Category: Gastrointestinal coating agents

These medications coat the ulcerated surfaces and are used mainly for peptic ulcer disease. May be used as a second agent with an H2 antagonist and in radiation esophagitis.

Drug Category: Proton pump inhibitors

These agents inhibit gastric acid secretion by inhibiting the H⁺/K⁺-ATPase enzyme system in gastric parietal cells. Newer products such as pantoprazole, lansoprazole, esomeprazole, and rabeprazole have recently been approved by the FDA and are at least as effective as the time-honored omeprazole.

FOLLOW-UP

Section 8 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Inpatient Care

• Admit the patient when significant bleeding, perforation, obstruction, or volume depletion occurs. Surgery (fundoplication) is sometimes indicated in patients with severe pain who fail to respond to medical management.

Further Outpatient Care

• The patient should receive follow-up care from his or her primary care provider. Refer the patient for endoscopy in the presence of suspected complications such as strictures, minor bleeding not requiring admission, and failure of medical therapy.

In/Out Patient Meds

• Previously, histamine-2 receptor antagonist therapy has been recommended as the initial treatment; however, newer evidence in cost-effectiveness analysis and symptomatic relief suggests proton pump inhibitors (omeprazole 20 mg daily, pantoprazole 40 mg daily, or lansoprazole 30 mg daily for 4-8 wk) to be superior to ranitidine, cimetidine, and placebo.
• Cisapride, a gastroprokinetic agent, and sucralfate, a coating agent, are less effective but may be useful in selected patients or as second-line agents.
• Although no consensus on treatment choice exists, prescribing for 2-4 weeks with reassessment is reasonable. Some patients with relapse may require long-term maintenance therapy.
• Some authorities suggest proton pump inhibitors and histamine-2 receptor antagonists for patients with ulcerlike dominant symptoms (eg, nocturnal symptoms, relief with food) and gastroprokinetic agents for patients with dysmotility dominant symptoms (eg, nausea, bloating).

Transfer

• Transfer patients with moderate-to-severe bleeding, obstruction, or perforation to a facility with endoscopic capabilities.

Complications

• Common complications of esophagitis are bleeding and stricture formation.
• Barrett esophagus, which occurs when the normal squamous epithelium of the esophagus is replaced with columnar epithelium, is linked to the development of esophageal cancer. A systematic review of patients with Barrett esophagus and colonic cancer also indicated a link between Barrett esophagus and colonic cancer (7.6% of patients with Barrett esophagus had colonic cancer vs 1.6% in controls).
• Although rare, perforation with mediastinitis is a serious complication.
• Volume depletion and weight loss may occur secondary to inability to swallow.
• Laryngitis, aspiration pneumonitis, and bronchospasm may occur if gastric contents are refluxed to the level of the larynx.
• Esophagitis also has been linked to failure to thrive and apnea in infants.
• Helicobacter pylori (HP) eradication therapy has been inversely related to reflux esophagitis. It is postulated that the ammonia (alkaline) produced by HP reduces the acidity of the stomach and, hence, protects the esophagus from acid spillage.

Prognosis

• Recurrence is a frequent problem in patients with reflux. Many patients require maintenance therapy for relapse of symptoms.

Patient Education

• Lifestyle changes recommended to reduce the frequency and amount of gastric contents that may reflux back into the esophagus include the following:
• • Elevate the head of the bed with 6-inch blocks. (Sleeping on extra pillows is discouraged because this actually may increase reflux by increasing intra-abdominal pressure caused by the patient bending at the waist.)
  • Stand upright for several hours after meals.
  • Reduce meal size.
  • Lose weight.
  • Quit smoking.
  • Avoid alcohol and caffeine.
  • Avoid citrus, spicy or fatty foods, and chocolate.
  • Avoid aggravating medications such as aspirin and other over-the-counter NSAIDs.
• For excellent patient education resources, visit eMedicine's Heartburn/GERD/Reflux Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Reflux Disease (GERD), Heartburn, and Understanding Heartburn/GERD Medications.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Do not misdiagnose cardiac chest pain as esophageal pain. Pain can be similar, particularly in elderly patients and women.
• Always consider cardiac causes of chest discomfort and treat appropriately. If the diagnosis is unclear, admission for further evaluation is suggested.

Special Concerns

• Infectious esophagitis is primarily seen in patients who are immunocompromised. The most common causes of infectious esophagitis are fungal (Candida species), herpetic (herpes simplex virus), and viral (cytomegalovirus). Odynophagia is a common presenting complaint. Endoscopy with biopsy and cultures is required for diagnosis. Treatment is directed toward the causative organism or organisms.
• Radiation esophagitis may occur with radiation treatment of cancers located in the chest (ie, lung, esophagus, mediastinum). Healing may not occur for several months after cessation of radiation therapy. Treatment is with viscous lidocaine and sucralfate. Stricture formation is a common complication and may require endoscopy for dilation.
• Pill-induced esophagitis is caused by ingesting medication with insufficient liquid and may be prevented by drinking larger quantities of fluid with medication. Certain medications (eg, iron, potassium, quinidine, tetracyclines, NSAIDs, aspirin, steroids) are more likely to cause esophagitis.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Peptic esophagitis. A rapid urease test (RUT) is performed on the esophageal biopsy sample. The result is positive for esophagitis.
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Media type:  Photo

Media file 2:  Corrosive esophagitis. This is a vinegar-induced esophageal burn. The patient had a fish bone in her throat. She ingested vinegar in an attempt to dissolve the fish bone but to no avail; this led to corrosive esophagitis.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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Article Last Updated: Nov 12, 2007