Esophagitis: Clinical sciences

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Introduction0:00–0:27

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.

History and Physical0:27–1:10

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.

Pill esophagitis1:10–2:41

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!

Reflux Esophagitis2:41–4:28

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!

Eosinophilic Esophagitis4:28–5:43

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. Treatment of eosinophilic esophagitis includes corticosteroids, and lifestyle modifications, such as avoidance of known allergens, some of which include certain foods.
Finally, some patients may require a surgical consultation for endoscopic esophageal dilation, to help alleviate dysphagia.Moving on to esophageal candidiasis!

Esophageal Candidiasis5:43–6:42

These individuals typically have history features pointing to immunosuppression, such as corticosteroids, or underlying conditions, like HIV infection, malignancy, and diabetes.
You might also find a history of recent antibiotic use, while the physical exam might reveal oral thrush. With these findings, you should suspect esophageal candidiasis, so, again, your next step is to order an EGD with a biopsy.
If EGD shows white plaques on the esophagus that do not easily wash off, and histopathology reveals yeast forms or pseudohyphae, diagnose esophageal candidiasis.
This is most commonly caused by the fungus Candida albicans, therefore the management primarily relies on systemic antifungals, like fluconazole.
Switching gears and moving on to viral esophagitis. This is typically associated with a more advanced form of immunocompromise, such as AIDS.

Viral Esophagitis6:42–7:48

Additionally, the physical exam might reveal fever and oral ulcers. These findings are highly suggestive of viral esophagitis, so your next step is to evaluate the patient’s esophagus using EGD with a biopsy.
EGD often shows esophageal ulcers and vesicles; while histopathology might reveal enlarged and multinucleated epithelial cells, and intranuclear or intracytoplasmic inclusions.
Additionally, the immunohistochemical staining might be positive for HSV or CMV, which are the two most common viruses associated with this type of esophagitis!
With these findings, you can diagnose viral esophagitis and start the treatment with antiviral medications, such as acyclovir for HSV, or ganciclovir for CMV.
Finally, let’s go over radiation esophagitis! These individuals typically present with a recent history of radiation therapy to malignancy of the head and neck, or in the chest area.

Radiation Esophagitis7:48–9:59

Keep in mind that, in addition to damaging cancerous cells, radiation can cause unintended damage to healthy cells as well.
In this case, suspect radiation esophagitis and order EGD with biopsy. The EGD will typically reveal a diffusely erythematous esophagus with superficial erosions.
There might also be bleeding, ulcers, and even strictures. Additionally, histopathology might reveal epithelial necrosis and cell atypia.
If you approach these findings, diagnose radiation esophagitis! Management generally focuses on symptom control, including topical anesthetics like viscous lidocaine; systemic analgesics for pain control; and acid-suppression medications, such as PPIs.
Additionally, encourage lifestyle modifications, such as eating softer foods and avoiding hot foods and liquids. If the patient has dysphagia due to strictures, they might need endoscopic esophageal dilation to improve swallowing.
Finally, consider holding off radiation treatments to allow for healing time, especially in severe cases of this type of esophagitis.
This decision must be a careful balance of the severity of the esophagitis versus the impact of stopping radiation. For instance, if your patient has radiation-sensitive curable cancer, avoid stopping at all costs; on the other hand, if they’re getting palliative radiation for a metastatic cancer, you can consider stopping the radiation at a milder problem.Now, one last clinical pearl!
If a patient on radiation treatment develops mild to moderate esophagitis, with no other apparent cause, you can diagnose radiation esophagitis clinically without EGD.
In this case, management is also topical anesthetics, systemic analgesics, and lifestyle modifications.Alright, as a quick recap… Esophagitis refers to the inflammation of the esophageal mucosa, characterized by chest pain, dysphagia, and odynophagia.

Review9:59–10:52

Identifying its underlying cause starts with a focused history and physical exam, EGD, and biopsies. Common types of esophagitis include pill esophagitis, reflux esophagitis, eosinophilic esophagitis, esophageal candidiasis, and viral esophagitis, as well as radiation esophagitis.
Treatment varies depending on the underlying cause, and may include supportive treatment and lifestyle modifications, acid-suppression medications, antivirals, antifungals, and glucocorticoids.
Finally, if your patient has severe esophagitis that’s refractory to medical management, they might need surgical consultation for esophageal dilation,