eMedicine Specialties > Gastroenterology > Esophagus

Esophagitis

Author: Sajid Ansari, MD, Consulting Staff, Department of Gastroenterology, St Anthony's Medical Center
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Dec 17, 2009

Introduction

Background

The most common cause of esophagitis is gastroesophageal reflux disease (GERD). Other important, but less common, causes are infections, medications, radiation therapy, systemic disease, and trauma. Eosinophilic esophagitis has emerged as an important cause of esophagitis in both children and adults. The image below demonstrates where fungal and viral infections occur in esophagitis-associated ulcers. This article does not discuss GERD -induced esophagitis.1

Esophagitis. Location of fungal and viral infecti...

Esophagitis. Location of fungal and viral infections in ulcers.

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Esophagitis. Location of fungal and viral infecti...

Esophagitis. Location of fungal and viral infections in ulcers.


Pathophysiology

The pathophysiology of esophagitis depends on its etiology. Infective esophagitis is most commonly observed in immunosuppressed hosts but has also been reported in healthy adults and children. A wide range of abnormalities in host defense may predispose an individual to opportunistic infections, such as neutropenia, impaired chemotaxis and phagocytosis, alteration in humoral immunity, and impaired T-cell lymphocyte function. Steroids, cytotoxic agents, radiation, and immune modulators can also contribute to impaired host immune function. Disruption of mucosal protective barriers and antibiotics that suppress the normal bacterial flora may contribute to the invasive ability of commensal organisms.2

The prevalence of symptomatic infection is high in individuals with AIDS, leukemia, and lymphoma and is low (<5%) in the general medical population. In people with HIV, the most significant risk factor is a persistently low CD4 count, but reports exist of individuals who develop fungal esophagitis during the seroconversion phase. Patients with systemic diseases (eg, diabetes mellitus, adrenal dysfunction, alcoholism) and those of advanced age can be predisposed to infectious esophagitis because of altered immune function. Illnesses that interfere with esophageal peristalsis, such as achalasia, progressive systemic sclerosis, and esophageal neoplasias, may contribute to fungal esophagitis.

Steroid therapy and other immunosuppressive medications contribute to fungal infection by suppressing both lymphocyte function and granulocyte function. Other medications associated with pill esophagitis cause injury by local or topical injury. Other medications, usually medications associated with pill esophagitis, cause injury by local contact.

The mechanism of eosinophilic esophagitis remains to be elucidated. However, a corrugated esophagus characterized by fine concentric mucosal rings is commonly observed in patients and believed to be related to histamine released from sensitized mast cells in the esophageal wall. This activates a cascade of reactions culminating in acetylcholine release that contracts muscle fibers in the muscularis mucosae resulting in the formation of concentric esophageal rings. This hypothesis can be tested by performing endoscopic ultrasound, which will reveal contraction of the muscle layers of the muscularis mucosae and may be related to immunoglobulin E (IgE) activation.

Frequency

United States

Unknown3

International

Unknown

Mortality/Morbidity

Patients may experience dysphagia, pain, odynophagia, and malnutrition in severe esophagitis.  Rarely, life-threatening bleeding occurs and may lead to death.  Outcomes and survival in these patients are related to the severity of their underlying systemic illness.

Race

No racial predilection is observed.

Sex

No sexual predilection is observed.

Age

No age-related differences are reported. Esophagitis is commonly seen in adults and is uncommon in childhood.4

Clinical

History

A history of immunosuppression, steroid therapy, recent antibiotic use, or systemic illness supports the diagnosis. Although patients may be asymptomatic, typical symptoms include the following:

  • Onset of difficult or painful swallowing (ie, dysphagia, odynophagia)
  • Heartburn
  • Retrosternal discomfort or pain
  • Nausea, vomiting
  • Fever, sepsis
  • Abdominal pain
  • Epigastric pain
  • Hematemesis (occasionally)
  • Anorexia, weight loss (depends on chronicity and severity of underlying illness)
  • Cough

Physical

  • Look for signs of immunosuppression and skin signs of systemic disease (eg, telangiectasias and sclerodactyly in scleroderma).
  • Examine the oral cavity (for thrush or ulcers).

Causes

See Histologic Findings.

More on Esophagitis

Overview: Esophagitis
Differential Diagnoses & Workup: Esophagitis
Treatment & Medication: Esophagitis
Follow-up: Esophagitis
Multimedia: Esophagitis
References
Further Reading
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References

  1. Dellon ES, Gibbs WB, Fritchie KJ, Rubinas TC, Wilson LA, Woosley JT, et al. Clinical, endoscopic, and histologic findings distinguish eosinophilic esophagitis from gastroesophageal reflux disease. Clin Gastroenterol Hepatol. Sep 2 2009;[Medline].

  2. Rothenberg ME. Biology and Treatment of Eosinophilic Esophagitis. Gastroenterology. Aug 14 2009;[Medline].

  3. Prasad GA, Alexander JA, Schleck CD, Zinsmeister AR, Smyrk TC, Elias RM, et al. Epidemiology of Eosinophilic Esophagitis Over 3 Decades in Olmsted County, Minnesota. Clin Gastroenterol Hepatol. Jul 1 2009;[Medline].

  4. Nurko S, Rosen R, Furuta GT. Esophageal Dysmotility in Children With Eosinophilic Esophagitis: A Study Using Prolonged Esophageal Manometry. Am J Gastroenterol. Sep 15 2009;[Medline].

  5. Wilheim AB, Miranda-Filho Dde B, Nogueira RA, et al. The resistance to fluconazole in patients with esophageal candidiasis. Arq Gastroenterol. Jan-Mar 2009;46(1):32-7. [Medline].

  6. Amaro R, Poniecka AW, Goldberg RI. Herpes esophagitis. Gastrointest Endosc. Jan 2000;51(1):68. [Medline].

  7. 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].

  8. Arora AS, Yamazaki K. Eosinophilic esophagitis: asthma of the esophagus?. Clin Gastroenterol Hepatol. Jul 2004;2(7):523-30. [Medline].

  9. AstraZeneca. Feldman's GastroAtlas Online. Available at: http://www.gastroatlas.com/login.aspx. [Full Text].

  10. 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.

  11. 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.

  12. Bradley J, Movsas B. Radiation esophagitis: Predictive factors and preventive strategies. Semin Radiat Oncol. Oct 2004;14(4):280-6. [Medline].

  13. 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].

  14. 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].

  15. 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].

  16. 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].

  17. Liacouras CA, Ruchelli E. Eosinophilic esophagitis. Curr Opin Pediatr. Oct 2004;16(5):560-6. [Medline].

  18. Lowe RC, Wolfe MM. The pharmacological management of gastroesophageal reflux disease. Minerva Gastroenterol Dietol. Sep 2004;50(3):227-37. [Medline].

  19. 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].

  20. Mann NS, Leung JW. Pathogenesis of esophageal rings in eosinophilic esophagitis. Med Hypotheses. 2005;64(3):520-3. [Medline].

  21. 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].

  22. Medical Economics Staff. Physicians' Desk Reference. 55th ed. Medical Economics Company: Montvale, NJ; 2001.

  23. 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].

  24. 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].

  25. 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].

  26. 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].

  27. 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].

  28. 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].

  29. 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.

  30. Wilcox CM. Esophageal strictures complicating ulcerative esophagitis in patients with AIDS. Am J Gastroenterol. Feb 1999;94(2):339-43. [Medline].

  31. 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.

  32. Winstead NS, Bulat R. Pill Esophagitis. Curr Treat Options Gastroenterol. Feb 2004;7(1):71-76. [Medline].

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Further Reading

Clinical guidelines
Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.
American Gastroenterological Association Institute - Medical Specialty Society
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition - Professional Association. 2007 Aug. 22 pages. NGC:006013

Gastrointestinal complications of HIV.
New York State Department of Health - State/Local Government Agency [U.S.]. 2006 Oct. 17 pages. NGC:006477

ACR Appropriateness Criteria® dysphagia.
American College of Radiology - Medical Specialty Society. 1998 (revised 2007). 6 pages. NGC:006986

Esophageal dilation.
American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2006 May. 6 pages. NGC:004974


Clinical trials

Intravenous (IV) Pantoprazole in Erosive Esophagitis

A Study of Flovent in Patients With Eosinophilic Esophagitis

Fluticasone Versus Esomeprazole to Treat Eosinophilic Esophagitis

Dose-Ranging Study of Oral Viscous Budesonide in Pediatrics With Eosinophilic Esophagitis


Related eMedicine topics

 Esophagitis (Emergency Medicine)

Esophagitis (Pediatrics: General Medicine)

Esophagitis, Infectious (Radiology)

Gastroesophageal Reflux Disease

Gastroesophageal Reflux

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Keywords

esophagitis, eosinophilic esophagitis, Candida esophagitis, herpes esophagitis, esophagogastroduodenoscopy, esophageal ulcer, esophageal ulcers, achalasia

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

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: Nothing to disclose.

Medical Editor

Maurice A Cerulli, MD, Program Director, Division of Gastroenterology and Hepatology, Associate Professor of Clinical Medicine, Albert College of Medicine Program in Gastroenterology at Long Island Jewish Medical Center
Maurice A Cerulli, 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 Medical Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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