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. This article does not discuss GERD-induced esophagitis.
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.
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
Unknown
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.
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.
- Infectious causes include the following:
- Candida species
- Noncandidal fungi (eg, Aspergillus, Histoplasma, Cryptococcus, Blastomyces)
- Herpes simplex virus (HSV)
- Cytomegalovirus (CMV)
- Varicella-zoster virus (VZV)
- Epstein-Barr virus (EBV)
- In HIV-infected hosts - CMV, HSV, Mycobacterium avium-intracellulare, idiopathic
- Human papillomavirus (HPV)
- Poliovirus
- Bacterial species (eg, normal flora, Mycobacterium tuberculosis, Mycobacterium avium-intracellulare)
- Parasitic infections (eg, Chagas disease, Trypanosoma cruzi, Cryptosporidium, Pneumocystis, Leishmania donovani)
- Systemic illnesses include the following:
- Skin disorders
- Epidermolysis bullosa
- Pemphigus vulgaris
- Bullous pemphigoid
- Cicatricial pemphigoid
- Drug-induced skin disorders (eg, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis)
- Other skin disorders (eg, lichen planus, psoriasis, acanthosis nigricans, leukoplakia)
- Eosinophilic esophagitis
- Behçet disease
- Graft versus host disease (GVHD)
- Inflammatory bowel disease (Crohn disease)
- Sarcoidosis
- Chronic granulomatous disease
- Metastatic cancer
- Collagen vascular disease
- Medications
- Pill esophagitis (eg, Fosamax)
- Antibiotics (eg, tetracycline)
- Potassium
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Quinidine
- Chemotherapy (eg, dactinomycin, bleomycin, cytarabine, daunorubicin, 5-fluorouracil, methotrexate, vincristine)
- Radiation therapy
- Skin disorders
More on Esophagitis |
 Overview: Esophagitis |
| Differential Diagnoses & Workup: Esophagitis |
| Treatment & Medication: Esophagitis |
| Follow-up: Esophagitis |
| Multimedia: Esophagitis |
| References |
| Next Page » |
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
