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Esophagitis: Clinical practice

Esophagitis: Clinical practice


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USMLE® Step 2 style questions USMLE

1 questions

A 25-year-old man comes to the emergency department because of acute onset hoarseness of voice within the past 3 days. He also reports coughing, frequent throat clearing, and flu-like symptoms. He reports having an upper respiratory infection from babysitting his younger cousin 5 days ago. A laryngoscopy is done and shows erythematous and edematous laryngeal tissue. Which of the following is the next best step in management for this patient?

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Rishi Desai, MD, MPH

The esophagus is a 25-30 centimeter long muscular tube through which food and liquids pass from the pharynx to the stomach. At the top and bottom of the esophagus there are the upper and lower esophageal sphincter, respectively.

Esophagitis is inflammation of the esophagus, and it usually causes dysphagia or difficulty in swallowing, odynophagia or painful swallowing, and retrosternal chest pain.

If the cause is unclear, the usual workup includes an upper endoscopy with a biopsy. And in case of retrosternal chest pain, an electrocardiogram should always be done in order to rule out cardiac ischemia.

Now, the most common cause is gastroesophageal reflux disease or GERD, and in that situation it’s called reflux esophagitis.

In reflux esophagitis, the tone of the lower esophageal sphincter is lower than normal so it doesn’t have a tight grip and allows gastric acid to easily pass into the esophagus. Over time, that leads to inflammatory lesions in the esophagus.

In addition to the classic symptoms, reflux esophagitis can also cause heartburn and regurgitation.

In some cases, gastric acid can irritate the respiratory tract, cause symptoms like coughing, voice changes, and a feeling of a lump in the throat.

An upper endoscopy usually shows signs of erosion and these lesions can be classified using the Savary-Miller system or the Los Angeles system, both of which use a 4-point grading scale, where grade 1 or A is mild esophagitis and grade 4 or D is severe esophagitis.

Treatment of reflux esophagitis starts with proton pump inhibitors or PPIs such as omeprazole for 8 weeks. If symptoms disappear, then the dose of PPI is gradually decreased. If PPIs are needed for more than 6 months, then it’s replaced by histamine 2 receptor agonists or H2RAs. Now, if the symptoms recur, then the lowest dose of the medication that last controlled the symptoms is restarted.

For individuals with severe erosive esophagitis, a repeat upper endoscopy should be done after 8 weeks of treatment to make sure that it’s healing and to rule out malignancy.

In medication induced esophagitis, the most common situation is that a medication directly injures the esophagus, especially if it’s taken with a small amount of water.

Common medications are nonsteroidal anti-inflammatories or NSAIDs such as ibuprofen and aspirin which disrupt the protective prostaglandine barrier, antibiotics like doxycycline which cause a local acid burn, potassium chloride which can increase local osmolality leading to tissue damage, and bisphosphonates like alendronate.

Symptom onset can vary from a few hours to a few weeks after taking the medication. In addition to the classic symptoms, medication induced esophagitis can also rarely cause upper gastrointestinal bleeding and weight loss.

In severe cases, an upper endoscopy is performed and typically shows ulcers that are mainly in the middle of the esophagus. The lesions are sometimes coated with medication material, and in rare cases medication fragments have to be removed during the procedure.

Treatment of medication induced esophagitis is mainly stopping the medication that caused esophagitis or in some cases - switching to a liquid version of the medication.

Starting the individual on PPIs reduces gastric acid production and can also help reduce symptoms.

Treatment is continued until symptoms disappear and the culprit medication can be re-initiated if it’s absolutely needed.

To prevent medication induced esophagitis, it’s often best to take medication with a full glass of water.

In caustic esophagitis, caustic agents which are strong acids like vinegar or strong bases like detergents are ingested either accidentally - usually by children, or voluntarily by adults usually in a suicide attempt, and it leads to esophageal lesions.

Generally speaking, strong bases are more injurious to the esophagus because they cause liquefaction necrosis and thermal burns which can penetrate deeper into the tissue, while strong acids cause superficial coagulation necrosis and formation of eschars that limit the depth of injury.

Individuals typically have retrosternal chest pain and odynophagia immediately after ingestion.

Oral burns can produce pain and drooling and there may be respiratory symptoms, like stridor, dyspnea and voice changes.

Caustic injuries to the esophagus are emergencies. Thoracic Xrays and a CT scan are typically done right away to look for complications like an esophageal perforation. In addition, an upper endoscopy should be done as soon as possible.

The esophageal lesions are most often classified using Zargar’s 4 point grading system, where a 4 is a severe injury, and a 1 is a mild injury. The higher the grade, the higher the risk for complications like esophageal strictures.

There should never be an attempt to neutralize the pH in the esophagus, by giving more chemicals, because this can cause further injury. In addition, emesis should never be induced because the gastric acid causes more damage to the esophagus.

Treatment of caustic esophagitis includes general measures like airway protection- in severe cases, the individual needs to be intubated, hemodynamic stabilization with intravenous fluids to prevent dehydration, and broad spectrum antibiotics to prevent an infection. In addition, in severe injuries, a nasogastric feeding tube is carefully inserted and the individual is placed on a liquid diet.

If the lesions are extensive or if there’s an esophageal perforation, then an esophagectomy-which is the surgical removal of the esophagus and colonic or jejunal replacements may be needed.

In eosinophilic esophagitis, also known as allergic esophagitis, the esophagus gets inflamed as a reaction to allergens, food or acid reflux. This happens mostly in males and in children, especially in individuals who also have allergic diseases, like seasonal allergies, atopic dermatitis, and asthma.

Symptoms in children can be atypical, and may include failure to thrive, refusal to swallow, regurgitation, and vomiting.

During an upper endoscopy, eosinophilic esophagitis has non-specific findings like mucosal fragility and esophageal rings- which are thin mucosal bands that surround the esophagus. Typically, a biopsy will show an increased number of intraepithelial eosinophils and microabscesses with large clusters of eosinophils near the surface.

Treatment of eosinophilic esophagitis begins with doing a prick skin test to identify potential foods that are triggers, so that these foods can be avoided.