Esophagitis - Clinicals, Diagnosis, and Management

Gastroenterology

Clinicals - History

Fact Explanation
Asymptomatic Some patients with esophagitis can be asymptomatic. Asymptomatic
Some patients with esophagitis can be asymptomatic.
Dyspepsia Dyspepsia (heart burn) is the most common presentation of the esophagitis. Reflux of acidic gastric contents in to the esophagus causes dyspepsia. Dyspepsia
Dyspepsia (heart burn) is the most common presentation of the esophagitis. Reflux of acidic gastric contents in to the esophagus causes dyspepsia.
Chest pain Retrosternal or epigastric burning pain is characteristic of reflux esophagitis. Chest pain
Retrosternal or epigastric burning pain is characteristic of reflux esophagitis.
Water brash Water brash is the increased production of saliva. It is seen in reflux esophagitis. Water brash
Water brash is the increased production of saliva. It is seen in reflux esophagitis.
Regurgitation Regurgitation of acidic gastric contents occurs in reflux esophagitis. Some patients complain of reflux of bitter taste. Regurgitation is frequent when the patient is in supine position, bending forwards or wearing tight clothes after a heave meal. Regurgitation
Regurgitation of acidic gastric contents occurs in reflux esophagitis. Some patients complain of reflux of bitter taste. Regurgitation is frequent when the patient is in supine position, bending forwards or wearing tight clothes after a heave meal.
Upper abdominal discomfort This is due to irritation of the esophagus due to acid reflux. Some complain of abdominal bloating sensation. Upper abdominal discomfort
This is due to irritation of the esophagus due to acid reflux. Some complain of abdominal bloating sensation.
Nausea and or vomiting Patients with esophagitis can have anorexia, nausea and vomiting. Nausea and or vomiting
Patients with esophagitis can have anorexia, nausea and vomiting.
Dysphagia Patients complain of dysphagia which occurs secondary to fibrosis and stricture formation. Some patients complain of odynophagia and sensation of food getting stuck in the mid-esophagus as well. These complaints are common in infective esophagitis (candida, cytomegalovirus, herpes simplex virus and HIV), eosinophilic esophagitis. Dysphagia
Patients complain of dysphagia which occurs secondary to fibrosis and stricture formation. Some patients complain of odynophagia and sensation of food getting stuck in the mid-esophagus as well. These complaints are common in infective esophagitis (candida, cytomegalovirus, herpes simplex virus and HIV), eosinophilic esophagitis.
Symptoms of lower respiratory tract infection Patients can have aspiration pneumonia secondary to aspiration of gastric contents in to the bronchi. Cough, wheezing, pleuritic chest pain and fever are symptoms of lower respiratory tract infection. Symptoms of lower respiratory tract infection
Patients can have aspiration pneumonia secondary to aspiration of gastric contents in to the bronchi. Cough, wheezing, pleuritic chest pain and fever are symptoms of lower respiratory tract infection.
Cough Cough can be secondary to laryngeal inflammation. Cough
Cough can be secondary to laryngeal inflammation.
Hoarseness of voice Irritation of vocal cords can cause hoarseness of voice. Hoarseness of voice
Irritation of vocal cords can cause hoarseness of voice.
Fever Patients with infective esophagitis can have fever. Classic triad of odynophagia, retrosternal pain and fever is seen in patients with herpes simplex virus esophagitis. Fever
Patients with infective esophagitis can have fever. Classic triad of odynophagia, retrosternal pain and fever is seen in patients with herpes simplex virus esophagitis.
Hematemesis Hematemesis is seen in patients with Herpes simplex virus esophagitis. Hematemesis
Hematemesis is seen in patients with Herpes simplex virus esophagitis.
Risk factors Obese patients are at risk of reflux esophagitis. Immunecompromised patients either acquired or congenital, are at risk of developing herpes esophagitis and candida esophagitis. Risk factors
Obese patients are at risk of reflux esophagitis. Immunecompromised patients either acquired or congenital, are at risk of developing herpes esophagitis and candida esophagitis.
Drug history Certain drugs like alendronate, doxycycline and other antibiotics can cause drug induced esophagitis. Drug history
Certain drugs like alendronate, doxycycline and other antibiotics can cause drug induced esophagitis.

Clinicals - Examination

Fact Explanation
BMI Most of the patients with GERD are obese. BMI
Most of the patients with GERD are obese.
Examination of the oral cavity In patients with oropharyngeal candidiasis, oral thrush will be seen as curd like white plaques. Examination of the oral cavity
In patients with oropharyngeal candidiasis, oral thrush will be seen as curd like white plaques.
Varicella zoster skin lesions Patients with varicella zoster have simultaneous dermatological involvement. Vesicular lesions are seen in the oral mucosa as well. Varicella zoster skin lesions
Patients with varicella zoster have simultaneous dermatological involvement. Vesicular lesions are seen in the oral mucosa as well.
Signs of lower respiratory tract infection Patients with GERD can have respiratory tract infections secondary to aspiration of gastric contents in to the bronchi. Patients are febrile, and have evidence of pulmonary consolidation. Commonly over the base of the right lung. Signs of lower respiratory tract infection
Patients with GERD can have respiratory tract infections secondary to aspiration of gastric contents in to the bronchi. Patients are febrile, and have evidence of pulmonary consolidation. Commonly over the base of the right lung.

Investigations - Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy (UGIE) UGEI helps in diagnosing the presence of esophagitis. Reflux esophagitis is characterized by the presence of erythema, edema, and linear ulcers over the distal esophagus.
Candida esophagitis can be diagnosed by the presence of curd like white plaques. In advanced disease luminal narrowing can be seen.
Herpes esophagitis have vesicles which later progress to linear ulcers. These are commonly observed over the mid and distal esophagus.
Endoscopic features of eosinophilic esophagitis include the presence of mucosal rings, furrows and white specks with narrow lumen.
UGIE can also detect the presence of concurrent hiatal hernia.
Upper gastrointestinal endoscopy (UGIE)
UGEI helps in diagnosing the presence of esophagitis. Reflux esophagitis is characterized by the presence of erythema, edema, and linear ulcers over the distal esophagus.
Candida esophagitis can be diagnosed by the presence of curd like white plaques. In advanced disease luminal narrowing can be seen.
Herpes esophagitis have vesicles which later progress to linear ulcers. These are commonly observed over the mid and distal esophagus.
Endoscopic features of eosinophilic esophagitis include the presence of mucosal rings, furrows and white specks with narrow lumen.
UGIE can also detect the presence of concurrent hiatal hernia.
Biopsy Herpes esophagitis is characterized by the presence of inflammation, multinucleated giant cells, ballooning degeneration of the cells, ground glass appearance of the nuclei and inclusion bodies.
Eosinophilic esophagitis is diagnosed by the presence of 15 or more intraepithelial eosinophils per high-power field (GERD patients can also have increased numbers of eosinophils in the esophagus). Presence of epithelial basal cell hyperplasia, and elongated lamina propria papillae are histological features of reflux esophagitis.
Biopsy
Herpes esophagitis is characterized by the presence of inflammation, multinucleated giant cells, ballooning degeneration of the cells, ground glass appearance of the nuclei and inclusion bodies.
Eosinophilic esophagitis is diagnosed by the presence of 15 or more intraepithelial eosinophils per high-power field (GERD patients can also have increased numbers of eosinophils in the esophagus). Presence of epithelial basal cell hyperplasia, and elongated lamina propria papillae are histological features of reflux esophagitis.
Culture Obtained biopsy samples can be used to isolate the possible organism. Viral cultures and fungal cultures are indicated whenever needed. Culture
Obtained biopsy samples can be used to isolate the possible organism. Viral cultures and fungal cultures are indicated whenever needed.
Polymerase chain reaction (PCR) PCR can identify the genome of the virus causing esophagitis. It has 92% to 100% sensitivity and 100% specificity. Polymerase chain reaction (PCR)
PCR can identify the genome of the virus causing esophagitis. It has 92% to 100% sensitivity and 100% specificity.
Direct immunofluorescence assays This is 69 to 88% sensitive in isolating the infectious organism in infectious esophagitis. Direct immunofluorescence assays
This is 69 to 88% sensitive in isolating the infectious organism in infectious esophagitis.
24 hour esophageal PH monitoring This aids in diagnosing GERD induced esophagitis. 24 hour esophageal PH monitoring
This aids in diagnosing GERD induced esophagitis.

Investigations - Management

Fact Explanation
Upper gastrointestinal endoscopy Patients with long term GERD can have Barrett esophagus as a complication of chronic acid reflux. Endoscopic screening is indicated if Barrett esophagus is suspected. In patients with endoscopic evidence of dysplasia annual endoscopic surveillance is indicated. If the subsequent endoscopies shows no dysplasia for two consecutive years endoscopy is done in every 3 years. Patients with persistent low-grade dysplasia should undergo endoscopic surveillance once in every 6 months intervals for a year and if they shows no progression of the lesions annual surveillance is adequate. Upper gastrointestinal endoscopy
Patients with long term GERD can have Barrett esophagus as a complication of chronic acid reflux. Endoscopic screening is indicated if Barrett esophagus is suspected. In patients with endoscopic evidence of dysplasia annual endoscopic surveillance is indicated. If the subsequent endoscopies shows no dysplasia for two consecutive years endoscopy is done in every 3 years. Patients with persistent low-grade dysplasia should undergo endoscopic surveillance once in every 6 months intervals for a year and if they shows no progression of the lesions annual surveillance is adequate.

Management - Supportive

Fact Explanation
Health education Obese patients with GERD should reduce weight. Patients should not take heave meals, lie down or bend forwards within about 3 hours of meals. It is better to avoid fried or fatty foods, chocolate, peppermint, coffee, carbonated beverages, citrus fruit juices, spicy foods, coffee, smoking and alcohol. Head end of the bed should be elevated. Health education
Obese patients with GERD should reduce weight. Patients should not take heave meals, lie down or bend forwards within about 3 hours of meals. It is better to avoid fried or fatty foods, chocolate, peppermint, coffee, carbonated beverages, citrus fruit juices, spicy foods, coffee, smoking and alcohol. Head end of the bed should be elevated.
Analgesics Patients who complain of pain need analgesics to relieve pain. Analgesics
Patients who complain of pain need analgesics to relieve pain.
Antipyeritics Patients with fever benefit from antipyretics. Antipyeritics
Patients with fever benefit from antipyretics.
Hydration and nutrition Patients who have dysphagia and odynophagia may need intravenous fluids and or nutrition. Hydration and nutrition
Patients who have dysphagia and odynophagia may need intravenous fluids and or nutrition.
Management of dysphagia Patients with dysphagia benefit from endoscopic dilatation. Intralesional injection of corticosteroids is also a treatment option for dysphagia secondary to stricture formation. Management of dysphagia
Patients with dysphagia benefit from endoscopic dilatation. Intralesional injection of corticosteroids is also a treatment option for dysphagia secondary to stricture formation.

Management - Specific

Fact Explanation
Proton pump inhibitors (PPIs) PPIs (omeprazole, pantoprazole, lansoprazole) are the first line medical management option in treating patients with esophagitis secondary to GERD. PPIs are usually prescribed for 4 to 8 weeks. Delayed release PPIs are better prescribed 30 to 60 minutes before meals.
Often therapeutic trial of PPIs is recommended to establish the diagnosis of GERD. Rapid symptomatic relief of symptoms in response to PPIs favors the diagnosis of GERD.
Proton pump inhibitors (PPIs)
PPIs (omeprazole, pantoprazole, lansoprazole) are the first line medical management option in treating patients with esophagitis secondary to GERD. PPIs are usually prescribed for 4 to 8 weeks. Delayed release PPIs are better prescribed 30 to 60 minutes before meals.
Often therapeutic trial of PPIs is recommended to establish the diagnosis of GERD. Rapid symptomatic relief of symptoms in response to PPIs favors the diagnosis of GERD.
Histamine-2 receptor antagonist (H2RA) H2RAs (ranitidine, cimetidine) are also used to treat GERD. This is better for maintenance therapy for symptomatic patients who have already prescribed PPIs. Histamine-2 receptor antagonist (H2RA)
H2RAs (ranitidine, cimetidine) are also used to treat GERD. This is better for maintenance therapy for symptomatic patients who have already prescribed PPIs.
Anti-reflux surgery Anti-reflux surgery is indicated in patients with GERD whose symptoms fail to respond to medical treatment. Laparoscopic or open Nissen and partial fundoplications techniques are used in the treatment. Anti-reflux surgery
Anti-reflux surgery is indicated in patients with GERD whose symptoms fail to respond to medical treatment. Laparoscopic or open Nissen and partial fundoplications techniques are used in the treatment.
Treatment of fungal esophagitis Mild fungal infection can be treated with topical nystatin, clotrimazole, and oral amphotericin B. Fluconazole and itraconazole oral preparations can also be used. Intravenous preparations used for severe infection include, amphotericin B, fluconazole, and flucytosine. Treatment of fungal esophagitis
Mild fungal infection can be treated with topical nystatin, clotrimazole, and oral amphotericin B. Fluconazole and itraconazole oral preparations can also be used. Intravenous preparations used for severe infection include, amphotericin B, fluconazole, and flucytosine.
Treatment of Herpes simplex virus esophagitis Herpes simplex virus esophagitis is a self-limiting condition in immune-competent patients. Antiviral treatment may be needed in severe infection or in immunocompromised patients. Acyclovir is commonly used for the treatment. Treatment of Herpes simplex virus esophagitis
Herpes simplex virus esophagitis is a self-limiting condition in immune-competent patients. Antiviral treatment may be needed in severe infection or in immunocompromised patients. Acyclovir is commonly used for the treatment.

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