Esophagitis: Clinical sciences

Esophagitis refers to the inflammation of the esophageal mucosa, which can be due to a wide range of underlying causes. This includes certain medications, pre-existing conditions like gastroesophageal reflux diseases, eosinophilic infiltration of the esophageal mucosa, infections, or even radiation exposure.

If a patient presents with a chief concern suggesting esophagitis, the first step is to obtain a focused history and physical examination. Your patient will likely report chest pain or upper abdominal discomfort, as well as symptoms like dysphagia and odynophagia. Additionally, some patients may report nausea, vomiting, and unintentional weight loss. The physical exam might reveal abnormalities in the oropharyngeal cavity, such as dental erosions, halitosis, oral thrush, or ulcers. If your patient presents with these signs and symptoms, you should suspect esophagitis and assess for an underlying cause.

Let’s start with pill esophagitis! In this case, your patient will report that these symptoms started after taking certain oral medications, especially tetracyclines, NSAIDs, and bisphosphonates. Most of these patients usually report taking their medications right before sleep, or with little or no fluids.

These findings are highly suggestive of pill esophagitis, so your next step is to discontinue the suspected medication. If your patient’s symptoms improve within 7 days, this confirms the diagnosis of pill esophagitis.

In this case, management focuses on patient education, which includes instructing your patient to take medications sitting upright and with plenty of fluid. You should also encourage your patient to remain upright for at least 30 minutes after taking the medications.

Now, here’s a clinical pearl to keep in mind! Sometimes your patient’s symptoms will not resolve after discontinuing the medication. In this case, order esophagogastroduodenoscopy, or EGD for short, which might reveal a discrete erosion or ulceration of esophageal mucosa, or even bleeding or strictures. These findings along with the history also confirm the diagnosis of pill esophagitis. In addition to patient education, you can treat these individuals with medications that inhibit gastric acid secretion, such as proton pump inhibitors.

Now, moving on to reflux esophagitis! Let’s say your patient reports heartburn, acid reflux, and a sour taste in their mouth; with or without dental erosions or halitosis on a physical exam. If your patient presents with these findings, suspect reflux esophagitis and order an EGD with biopsy. Typical EGD findings include superficial erosions, while histopathology reveals a friable epithelium.

In severe cases of reflux esophagitis, histopathology may reveal Barrett esophagus. In this condition, the normal squamous epithelium of the esophagus (img 1) undergoes metaplasia and becomes nonciliated columnar epithelium with goblet cells (img 2). This reflects an increased risk of progression to esophageal adenocarcinoma. At this point, you can diagnose reflux esophagitis!

Management involves acid-suppression medications, such as proton pump inhibitors, and lifestyle modifications, such as weight loss and elevating the head of the bed. In the case of Barrett esophagus, your patient will need regular EGD screenings for adenocarcinoma.

Additionally, they might need a surgical consultation for possible endoscopic ablation or laparoscopic fundoplication. Endoscopic ablation treats precancerous lesions caused by chronic reflux of gastric contents; while laparoscopic fundoplication involves wrapping the top part of the stomach around the lower portion of the esophagus, forming an artificial valve that prevents further refluxes.

Next up is eosinophilic esophagitis! In this case, your patient typically reports a history of an atopic disease, such as asthma or allergic rhinitis. Additionally, the physical exam might reveal wheezing or atopic dermatitis. If you have these findings, suspect eosinophilic esophagitis,

which is a chronic inflammation of the esophagus caused by antigen sensitization! To confirm the diagnosis, you need to order an EGD with a biopsy. The EGD will often reveal the narrowing of the esophagus, concentric rings, and linear furrows, while histopathology shows eosinophils in the squamous epithelium. If you have these findings, diagnose eosinophilic esophagitis.