eMedicine Specialties > Gastroenterology > Esophagus
Esophagitis: Differential Diagnoses & Workup
Updated: Jul 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Angina Pectoris
Gastroesophageal Reflux Disease
Peptic Ulcer Disease
Pulmonary Embolism
Other Problems to Be Considered
Coronary artery disease
Pericarditis
Aortic aneurysm
Nonulcer reflux disease
Functional dyspepsia
Stricture
Workup
Laboratory Studies
- CBC count in patients with neutropenia or who are immunosuppressed
- CD4 count and HIV test in patients with risk factors for HIV
Imaging Studies
- Barium studies are recommended as the initial imaging study in patients presenting with dysphagia.
- A case can be made for initial upper endoscopy because this approach would reveal more diagnostic information (eg, inflammatory characteristics, ability to obtain samples for pathological examination, cytological examination, viral and bacterial cultures). Barium studies are less accurate for mucosal detail and can also reduce the capability of obtaining positive cultures.
- The authors do not recommend barium studies for patients with absolute dysphagia or odynophagia. Upper endoscopy would be recommended under these circumstances. The authors view barium studies and upper endoscopy as complementary rather than competing tests in the evaluation of patients with dysphagia.
Other Tests
- No specific other tests are recommended; other tests are performed based on underlying disease (eg, CD4 count in HIV, CBC count in neutropenia) and collagen workup (eg, antinuclear antibody [ANA], anti-dsDNA).
Procedures
- Esophagogastroduodenoscopy (EGD) is preferred in patients with odynophagia because this is a specific symptom of esophagitis. EGD is the main diagnostic tool used for esophagitis.
- Allows mucosal visualization
- Can obtain mucosal biopsies and brushings
- Wide variety of findings based on the underlying cause
- Blind brush cytology has been used in the past; however, with the availability of EGD, its use has diminished. It is performed by passing a cytology brush in a sheath similar to a nasogastric or orogastric tube. Once the end of the catheter is in the mid esophagus, the brush is extended and brushings are taken. Finally, the brush is withdrawn back into the sheath. This is performed without any direct visualization, as occurs when brushings are performed during an EGD.
Histologic Findings
Candida
Oral thrush is a frequent finding and is often an indicator of esophageal involvement. Oral thrush can be absent in 25% of cases of Candida esophagitis. Candida infection is frequently asymptomatic.
The grading scale for candidal esophagitis is as follows:
- Grade 1 - Few raised white plaques up to 2 mm in size, no ulceration
- Grade 2 - Multiple raised white plaques more than 2 mm in size, no ulceration
- Grade 3 - Confluent, linear, nodular, elevated plaques with ulceration
- Grade 4 - Grade 3 with narrowed lumen
Candida plaques are typically creamy white or pale yellow, with underlying raw mucosa. Brushings should be obtained with a sheathed cytology brush, spread onto slides, and stained with periodic acid-Schiff, silver, or Gram stains. The presence of mycelial forms and masses of budding yeast is consistent with candidal infection. Cultures are seldom indicated because Candida species are commensal organisms, and differentiating normal flora from infection is difficult. Cultures are useful for resistant Candida or Aspergillus.
Herpes simplex virus
HSV esophagitis diagnosis is made at endoscopy. The earliest esophageal lesions are rounded 1- to 3-mm vesicles in the middle to distal esophagus. Centers slough to form discrete circumscribed ulcers with raised edges.
Advanced HSV esophagitis may be indistinguishable from candidal esophagitis. Plaques, cobblestoning, or a shaggy ulcerative appearance is observed.
HSV preferentially infects epithelial cells. Biopsy should be performed on ulcer margins of islands of squamous mucosa for histology and culture (see Media file 1).
The ulcer base is devoid of epithelial cells and is inadequate to diagnose HSV esophagitis.
Immunologic staining of centrifugation cultures is more sensitive than routine histology.
- Multinucleated giant cells
- Ballooning degeneration
- Ground glass intranuclear Cowdry type A inclusion bodies
- Margination of chromatin
Immunohistologic stains using monoclonal antibodies to HSV antigens or in situ hybridization techniques may improve the yield in difficult cases.
Cytomegalovirus
See Cytomegalovirus Esophagitis. The virus infects submucosal fibroblasts and endothelial cells, not the squamous epithelium (see Media file 1). Diagnosis depends on biopsies from the EGD. Superficial erosions with serpiginous nonraised borders in the middle to distal esophagus are observed. With infection progression, shallow ulcerations may deepen and expand for 5-10 cm. Tissue is needed for confirmation; obtain multiple biopsies from the ulcer base.
Varicella-zoster virus
This organism can cause severe esophagitis. The key to diagnosis is finding concurrent dermatologic VZV lesions. The appearance on EGD ranges from occasional vesicles to discrete ulcerative lesions to a confluence of ulcerations with necrosis. On histologic examination, epithelial cells with VZV show edema, ballooning degeneration, and multinucleated giant cells with intranuclear eosinophilic inclusion bodies. Immunohistochemical staining using monoclonal antibodies is helpful to differentiate VZV from HSV.
Epstein-Barr virus
Histologic features of esophageal lesions are similar to those of oral hairy leukoplakia.
Human immunodeficiency virus
Multiple, small, aphthoid lesions are observed during the period of transient fever, chills, malaise, and rash of early HIV infection. Later, giant deep ulcers extending up several centimeters are observed. Fistula formation, perforation, hemorrhage, or superinfection may complicate large ulcers.
Human papillomavirus
HPV esophagitis is asymptomatic. Lesions are typically found in the middle to distal esophagus. They may appear as erythematous macules, white plaques, nodules, or exuberant frondlike lesions. The diagnosis is made based on histology. Koilocytosis, giant cells, and cytologic atypia are visible on immunohistochemical stains.
Mycobacterium tuberculosis
Esophageal symptoms result from direct extension from adjacent mediastinal structures. EGD reveals shallow ulcers, heaped-up lesions mimicking neoplasia, and extrinsic compression of the esophagus. Specimens should be sent for acid-fast stains and mycobacterial culture.
Drug-induced skin disease
Drug-induced skin diseases, which rarely occur, affect the esophagus with a blistering process and desquamation of large areas of epithelium. Both focal and long strictures and webs may form.
Behçet disease
Esophageal involvement is rare. Esophageal lesions include ulcerations that can tunnel the mucosa, strictures, fistulous tracts, and perforations.
Graft versus host disease
Histologic changes in acute GVHD are observed in the squamous epithelium, including the esophagus. Chronic GVHD damages the esophagus more extensively. Generalized desquamation is visible on EGD. Barium contrast radiographs may reveal webs, rings, and tight strictures in the upper and mid esophagus.
Inflammatory bowel disease
The esophagus can be involved in Crohn disease. Aphthous ulcers are observed in the esophagus. Inflammatory strictures, sinus tracts, filiform polyps, and fistulas to adjacent structures may be observed. Histology shows diffuse and nodular lymphoid aggregates; 50% of EGD biopsy specimens show noncaseating granulomas.
Metastatic cancer
Diagnosis is best made by barium contrast radiography and CT scan. EGD is used to exclude primary esophageal cancer.
Collagen vascular diseases
Motility disorders of the esophagus lead to poor acid clearing, with resulting epithelial damage (ie, GERD in scleroderma).
Medications (pill esophagitis)
Antibiotics, potassium chloride, NSAIDs, quinidine, emperonium bromide, and Fosamax account for 90% of the reported cases. The following are important pill and patient factors:
- Chemical nature of drug
- Solubility
- Contact time with mucosa
- Size, shape, and pill coating
- Amount of water (ie, too little) taken to swallow pill (eg, Fosamax)
- Preexisting esophageal pathology (eg, stricture, achalasia)
EGD findings range from reddened edematous mucosa to small superficial ulcers to large ulcers with heaped up inflamed margins, often with exudate.
Chemotherapy esophagitis
Dactinomycin, bleomycin, cytarabine, daunorubicin, 5-fluorouracil, methotrexate, and vincristine may cause severe dysphagia because of oropharyngeal mucositis.
Radiation and chemoradiation esophagitis
Radiation therapy over 30 Gy to the mediastinum typically causes retrosternal burning and painful swallowing, which is usually mild and limited to the duration of therapy.
- A dose of 40 Gy causes mucosal redness and edema.
- A dose of 50 Gy causes a higher incidence and severity of esophageal damage.
- A dose of 60-70 Gy causes moderate-to-severe esophagitis with strictures, perforations, and fistulas.
Sclerosant and band ligation therapy for varices
This can cause necrosis of esophageal tissues and mucosal ulcers. Incidence and severity are higher with sclerosant therapy. Later, strictures can develop.
More on Esophagitis |
| Overview: Esophagitis |
 Differential Diagnoses & Workup: Esophagitis |
| Treatment & Medication: Esophagitis |
| Follow-up: Esophagitis |
| Multimedia: Esophagitis |
| References |
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References
Amaro R, Poniecka AW, Goldberg RI. Herpes esophagitis. Gastrointest Endosc. Jan 2000;51(1):68. [Medline].
Armstrong D, Marshall JK, Chiba N, Enns R, Fallone CA, Fass R, et al. Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults - update 2004. Can J Gastroenterol. Jan 2005;19(1):15-35. [Medline].
Arora AS, Yamazaki K. Eosinophilic esophagitis: asthma of the esophagus?. Clin Gastroenterol Hepatol. Jul 2004;2(7):523-30. [Medline].
AstraZeneca. Feldman's GastroAtlas Online. Available at: http://www.gastroatlas.com/login.aspx. [Full Text].
Baehr PH, McDonald GB. Esophageal disorders caused by infection, systemic illness, medications, radiation, and trauma. In: Sleisenger & Fordtran Gastrointestinal and Liver Disease. 6th ed. Philadelphia, Pa: WB Saunders Co; 1998:519-539.
Boyce HW. Medication induced esophagitis and caustic ingestion. In: AGA Spring Postgraduate Course. GI in the Next Century: Clinical Advances in Esophageal and Gastrointestinal Disorders. 1999.
Bradley J, Movsas B. Radiation esophagitis: Predictive factors and preventive strategies. Semin Radiat Oncol. Oct 2004;14(4):280-6. [Medline].
Cantù P, Velio P, Prada A, Penagini R. Ringed oesophagus and idiopathic eosinophilic oesophagitis in adults: an association in two cases. Dig Liver Dis. Feb 2005;37(2):129-34. [Medline].
Catalano F, Terminella C, Grillo C, Biondi S, Zappalà M, Bentivegna C. Prevalence of oesophagitis in patients with persistent upper respiratory symptoms. J Laryngol Otol. Nov 2004;118(11):857-61. [Medline].
Dieterich DT, Wilcox CM. Diagnosis and treatment of esophageal diseases associated with HIV infection. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. Nov 1996;91(11):2265-9. [Medline].
Donnellan C, Sharma N, Preston C, Moayyedi P. Medical treatments for the maintenance therapy of reflux oesophagitis and endoscopic negative reflux disease. Cochrane Database Syst Rev. 2005;(2):CD003245. [Medline].
Liacouras CA, Ruchelli E. Eosinophilic esophagitis. Curr Opin Pediatr. Oct 2004;16(5):560-6. [Medline].
Lowe RC, Wolfe MM. The pharmacological management of gastroesophageal reflux disease. Minerva Gastroenterol Dietol. Sep 2004;50(3):227-37. [Medline].
Malfertheiner P, Lind T, Willich S, Vieth M, Jaspersen D, Labenz J, et al. Prognostic influence of Barrett's oesophagus and Helicobacter pylori infection on healing of erosive gastro-oesophageal reflux disease (GORD) and symptom resolution in non-erosive GORD: report from the ProGORD study. Gut. Jun 2005;54(6):746-51. [Medline].
Mann NS, Leung JW. Pathogenesis of esophageal rings in eosinophilic esophagitis. Med Hypotheses. 2005;64(3):520-3. [Medline].
McColl KE. Review article: Helicobacter pylori and gastro-oesophageal reflux disease--the European perspective. Aliment Pharmacol Ther. Dec 2004;20 Suppl 8:36-9. [Medline].
Medical Economics Staff. Physicians' Desk Reference. 55th ed. Medical Economics Company: Montvale, NJ; 2001.
Mimidis K, Papadopoulos V, Margaritis V, Thomopoulos K, Gatopoulou A, Nikolopoulou V, et al. Predisposing factors and clinical symptoms in HIV-negative patients with Candida oesophagitis: are they always present?. Int J Clin Pract. Feb 2005;59(2):210-3. [Medline].
Noel RJ, Putnam PE, Collins MH, Assa'ad AH, Guajardo JR, Jameson SC, et al. Clinical and immunopathologic effects of swallowed fluticasone for eosinophilic esophagitis. Clin Gastroenterol Hepatol. Jul 2004;2(7):568-75. [Medline].
Patel AB, Edelman MJ, Kwok Y, Krasna MJ, Suntharalingam M. Predictors of acute esophagitis in patients with non-small-cell lung carcinoma treated with concurrent chemotherapy and hyperfractionated radiotherapy followed by surgery. Int J Radiat Oncol Biol Phys. Nov 15 2004;60(4):1106-12. [Medline].
Rath HC, Timmer A, Kunkel C, Endlicher E, Grossmann J, Hellerbrand C, et al. Comparison of interobserver agreement for different scoring systems for reflux esophagitis: Impact of level of experience. Gastrointest Endosc. Jul 2004;60(1):44-9. [Medline].
Rodrigues F, Brandão N, Duque V, Ribeiro C, António AM. Herpes simplex virus esophagitis in immunocompetent children. J Pediatr Gastroenterol Nutr. Nov 2004;39(5):560-3. [Medline].
Weigand K, Wagner-Thiessen E, Stolte M. Esophagitis in an adolescent patient with Crohn's disease after changing treatment from prednisolone to budesonide. Z Gastroenterol. Oct 2004;42(10):1179-81. [Medline].
Wilcox CM. Diagnosis and management of esophagitis in patients with AIDS. In: AGA Spring Postgraduate Course. GI in the Next Century: Clinical Advances in Esophageal and Gastrointestinal Disorders. 1999.
Wilcox CM. Esophageal strictures complicating ulcerative esophagitis in patients with AIDS. Am J Gastroenterol. Feb 1999;94(2):339-43. [Medline].
Wilcox CM. Esophagitis in the immunocompromised host. In: Castell DO, Richter JE, eds. The Esophagus. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:539-555.
Winstead NS, Bulat R. Pill Esophagitis. Curr Treat Options Gastroenterol. Feb 2004;7(1):71-76. [Medline].
Further Reading
Keywords
gastritis, peptic ulcer disease, PUD, gastroesophageal reflux disease, GERD, hiatal hernia, fungal esophagitis, Candida esophagitis, herpes simplex virus esophagitis, HSV esophagitis, cytomegalovirus esophagitis, CMV esophagitis, varicella-zoster virus esophagitis, VZV esophagitis, Epstein-Barr virus esophagitis, EBV esophagitis, HIV esophagitis, human papillomavirus esophagitis, HPV esophagitis, Mycobacterium tuberculosis esophagitis, drug-induced esophagitis, medication related-esophagitis, graft versus host disease esophagitis, eosinophilic esophagitis, infective esophagitis, infectious esophagitis, achalasia, progressive systemic sclerosis, esophageal neoplasias, steroid therapy, immunosuppressive medications, pill esophagitis, dysphagia, odynophagia, epidermolysis bullosa, Stevens-Johnson syndrome, toxic epidermal necrolysis, cicatricial pemphigoid, lichen planus, psoriasis, acanthosis nigricans, leukoplakia, pemphigus vulgaris, erythema multiforme, bullous pemphigoid, collagen vascular disease, metastatic cancer, chronic granulomatous disease, sarcoidosis, inflammatory bowel disease
