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Esophagitis Differential Diagnoses

  • Author: Deepika Devuni, MBBS; Chief Editor: BS Anand, MD  more...
Updated: Nov 12, 2015

Diagnostic ConsiderationsDiagnosis of Candida esophagitisDiagnosis of herpes esophagitisDiagnosis of cytomegalovirus esophagitisDiagnosis of HIV esophagitisDiagnosis of tuberculous esophagitisDiagnosis of eosinophilic esophagitis

Always consider the possibility of a systemic illness causing the esophageal manifestations (eg, AIDS, scleroderma, systemic lupus erythematosus, pemphigus). Always consider cardiac causes of chest discomfort and treat appropriately. If the diagnosis is unclear, admission for further evaluation is suggested. Do not misdiagnose cardiac chest pain as esophageal pain. Pain can be similar, particularly in elderly patients and women.

Go to Pediatric Esophagitis for complete information on this topic.

Conditions that may mimic symptoms of esophagitis include the following:

  • Coronary artery disease
  • Pericarditis
  • Aortic aneurysm
  • Nonulcer reflux disease
  • Functional dyspepsia
  • Stricture

Glycogenic acanthosis, reflux esophagitis, herpes esophagitis, and superficial spreading carcinoma may produce findings similar to those seen in Candida esophagitis. However, patients with glycogenic acanthosis are almost always older individuals who have no esophageal symptoms, and the mucosal nodules of glycogenic acanthosis tend to have a more rounded appearance, whereas the plaques of candidiasis are more linear.

Reflux esophagitis may also manifest as a nodular mucosa, but the nodules tend to be more poorly defined than those in candidiasis, and they are always contiguous with the gastroesophageal junction.

Occasionally, herpes esophagitis manifests as multiple plaquelike lesions in the esophagus, but this infection is more commonly associated with small superficial ulcers (see Diagnosis of Herpes Esophagitis, below). Superficial spreading carcinoma may also manifest as a nodular mucosa, but the nodules tend to have poorly defined borders, producing a confluent area of disease.

Undissolved effervescent particles and debris in the esophagus can be mistaken for the plaques of candidiasis. Thus, if infectious esophagitis is suggested clinically, a double-contrast study should initially be performed without the use of effervescent granules.

In the appropriate clinical setting, discrete superficial ulcers in the upper or mid esophagus without associated plaques should be highly suggestive of herpes esophagitis. In contrast, ulceration in Candida esophagitis almost invariably occurs on a background of extensive plaque formation. Candida and herpes esophagitis can often be diagnosed on double-contrast studies, obviating endoscopy. However, if radiographic findings are equivocal or if response to treatment is inadequate, endoscopy should be performed for a more definitive diagnosis.

Other causes of small superficial ulcers in the upper or mid esophagus include drug-induced esophagitis and Crohn disease. However, these entities usually can be differentiated from infectious esophagitis on the basis of the clinical history.

Because herpetic ulcers rarely become as large as those of infectious esophagitis, the presence of 1 or more giant ulcers suggests the possibility of CMV esophagitis in patients with AIDS. However, in patients who are HIV positive, giant esophageal ulcers can also be caused by HIV (see Diagnosis of HIV Esophagitis below).

Other causes of giant esophageal ulcers include nasogastric intubation; endoscopic sclerotherapy; caustic injuries; and oral medications, such as nonsteroidal anti-inflammatory drugs, potassium chloride, and quinidine. However, the correct diagnosis can almost always be suggested on the basis of the clinical history.

Go to Cytomegalovirus Esophagitis for complete information on this topic.

Because most HIV ulcers are indistinguishable from CMV ulcers on the basis of the clinical and radiographic criteria, CMV esophagitis must be excluded by means of endoscopy before a diagnosis of HIV esophagitis can be established. Biopsy specimens, brushings, and/or viral cultures from the esophagus may be needed.

Differentiating between these infections is essential because most cases of HIV esophagitis dramatically respond to treatment with oral steroids, whereas CMV esophagitis is treated with relatively toxic antiviral agents such as ganciclovir (see Cytomegalovirus Esophagitis). Endoscopy is required for a definitive diagnosis before patients are treated.

Erosion of caseating nodes into the esophagus may result in the development of longitudinal or transverse sinus tracts or esophageal-airway fistulas. Similar tracts and fistulas may be seen in patients with radiation esophagitis, Crohn disease, trauma, or esophageal cancer. However, in these patients, the clinical history usually suggests the correct diagnosis.

Intrinsic tuberculosis is extremely rare and is characterized by mucosal plaques, ulcers, strictures, and fistulas. The development of dysphagia, coughing, or choking during swallowing suggests the possibility of esophageal involvement or fistula formation in a patient with tuberculosis.

An increasingly recognized noninfectious form of esophagitis that may require differentiation from infectious esophagitis is eosinophilic esophagitis.[49] The majority of patients with this disorder present with intermittent difficulty in swallowing solid food. On barium studies, eosinophilic esophagitis typically produces a series of concentric rings in the esophagus.

In 2013, the American College of Gastroenterology issued a new guideline for the diagnosis and management of eosinophilic esophagitis.[50] Diagnostic recommendations include the following:

  • The underlying cause of esophageal eosinophilia should be identified
  • Eosinophilic esophagitis is defined by symptoms, histology, and treatment response
  • The distal and proximal esophagus should be biopsied, as should the antrum and/or duodenum, in all pediatric patients, as well as in adult patients with gastric or small intestinal symptoms or endoscopic abnormalities

Differential Diagnoses

Contributor Information and Disclosures

Deepika Devuni, MBBS Resident Physician, Department of Internal Medicine, University Of Connecticut School of Medicine

Disclosure: Nothing to disclose.


John W Birk, MD, FACG Associate Professor of Medicine, Director, Gastroenterology and Hepatology Fellowship Program, University of Connecticut School of Medicine; Chief, Division of Gastroenterology, University of Connecticut Health Center

John W Birk, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.


Sajid Ansari, MD Consulting Staff, Department of Gastroenterology, St Anthony's Medical Center

Sajid Ansari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF Associate Professor of Clinical Medicine, Albert Einstein College of Medicine of Yeshiva University; Associate Professor of Clinical Medicine, Hofstra Medical School

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chin Hung Chung, MBBS, FRCS(Glasg), FHKAM(Surgery) Chief of Service, Department of Accident and Emergency, North District Hospital, Hong Kong

Chin Hung Chung, MBBS, FRCS(Glasg), FHKAM(Surgery) is a member of the following medical societies: American College of Surgeons and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chun-hing Ludwig Tsoi MB, ChB, MPH, MRCP, FRCS(Edin), Senior Medical Officer, Accident and Emergency Department, Tseng Kwan O Hospital, Hong Kong; Chairman, Committee on Training, Hong Kong St John Ambulance

Chun-hing Ludwig Tsoi is a member of the following medical societies: Royal College of Physicians of the United Kingdom and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

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Esophagitis. Location of fungal and viral infections in ulcers.
Peptic esophagitis. A rapid urease test (RUT) was performed on the esophageal biopsy sample. The result was positive for Helicobacter pylori.
Corrosive esophagitis. This is a vinegar-induced esophageal burn. The patient had a fish bone in her throat. She ingested vinegar in an attempt to dissolve the fish bone but to no avail; this led to corrosive esophagitis.
Infectious esophagitis. Candida esophagitis. Double-contrast esophagram shows linear plaquelike lesions in the esophagus, with normal intervening mucosa.
Infectious esophagitis. Two examples of advanced Candida esophagitis demonstrate a shaggy esophagus. In both images, the double-contrast esophagram shows a grossly irregular esophageal contour due to innumerable plaques and pseudomembranes, with the trapping of barium between lesions. Patients with this fulminant form of esophageal candidiasis are almost always found to have acquired immunodeficiency syndrome (AIDS).
Infectious esophagitis. Candida esophagitis with a foamy esophagus. This patient has a dilated esophagus with beaklike narrowing (arrow) at the gastroesophageal junction as a result of long-standing achalasia. Innumerable tiny bubbles are layering out in the barium column due to infection by the yeast form of candidiasis.
Infectious esophagitis. Herpes esophagitis. Double-contrast esophagram shows small, discrete ulcers (arrows) in the mid esophagus on a normal background mucosa. Note the radiolucent mounds of edema surrounding the ulcers. In the appropriate clinical setting, this appearance is highly suggestive of herpes esophagitis, since ulceration in candidiasis almost always occurs on a background of diffuse plaque formation.
Infectious esophagitis. Cytomegalovirus esophagitis in a patient with acquired immunodeficiency syndrome (AIDS). Double-contrast esophagram shows a large, flat ulcer in profile (large arrows) in the mid esophagus with a cluster of small satellite ulcers (small arrows). Because HIV esophagitis may produce identical radiographic findings, endoscopy is required to confirm the presence of cytomegalovirus before patients are treated.
Infectious esophagitis. Two examples of giant human immunodeficiency virus (HIV) esophageal ulcers (arrows) in patients with acquired immunodeficiency syndrome (AIDS). In A, the ulcer is seen in profile, whereas in B, the ulcer is seen en face. Endoscopy is required to exclude cytomegalovirus as the cause of this finding before treating patients.
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