eMedicine Specialties > Gastroenterology > Esophagus
Esophagitis: Treatment & Medication
Updated: Jul 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Treatment is directed at the underlying cause. The goal of medical care is to treat the underlying cause and minimize morbidity. Treatment options are as follows:
- Candida esophagitis
- Topical nonabsorbable agents include nystatin, clotrimazole, and oral amphotericin B.
- Oral agents include fluconazole and itraconazole.
- Parenteral agents include amphotericin B, fluconazole, and flucytosine.
- Choice of agent depends on the severity of infection and degree of host defense impairment.
- HSV esophagitis diagnosis made at endoscopy
- Acyclovir
- Foscarnet for acyclovir-resistant cases
- Famciclovir (acyclovir analog)
- CMV esophagitis
- Ganciclovir (acyclovir analog)
- Foscarnet
- Varicella-zoster virus esophagitis
- Acyclovir
- Famciclovir
- Foscarnet for acyclovir-resistant cases
- EBV esophagitis: Acyclovir (may require long-term maintenance to suppress oral hairy leukoplakia)
- Human immunodeficiency virus esophagitis
- Corticosteroid therapy, usually for longer than 1 month
- Antiretroviral therapy for HIV
- Human papillomavirus esophagitis
- Often asymptomatic (No treatment is usually needed.)
- Systemic interferon-alfa, bleomycin, and etoposide used with variable results
- M tuberculosis esophagitis: Standard antituberculous therapy is used for immunocompetent hosts.
- Bacterial esophagitis: Normal flora, usually observed in immunocompromised patients, is extremely rare in healthy hosts.
- Infections are often polymicrobial and include Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus viridans, and Bacillus species.
- Broad-spectrum beta-lactam antibiotics are used, usually in combination with an aminoglycoside. Adjustments are based on response and culture results.
- Behçet disease esophagitis
- Corticosteroids for serious inflammation
- Chlorambucil or azathioprine for long-term therapy
- Graft versus host disease esophagitis
- Dilation and antireflux measures
- Prednisone, cyclosporine, azathioprine, and thalidomide
- Inflammatory bowel disease esophagitis
- Corticosteroid therapy for inflammatory lesions
- Dilation for strictures
- Surgery - May be needed for fistulas and strictures
- Metastatic cancer esophagitis
- Radiation therapy
- Palliation with stents
- Collagen vascular diseases esophagitis
- Medication-related esophagitis (pill esophagitis)
- Stop medication.
- Control of acid reflux may accelerate healing.
- Patients should take medication with plenty of water while sitting in the upright position.
- Chemotherapy esophagitis
- Radiation and chemoradiation esophagitis
Surgical Care
Surgical care may be necessary for perforation and fistulas.
Consultations
- Consult a gastroenterologist to facilitate diagnosis and treatment.
- Consulting an infectious disease specialist may be necessary in difficult cases.
- A surgical consultation may be necessary for perforation and fistulas.
- Other consultations may be sought, as indicated.
Diet
No particular restrictions are necessary. If the patient has odynophagia or is unable to consume calories orally, then gastric feeding or parenteral feeding may be needed.
Activity
No limitations on patient activity are necessary.
Medication
Therapy is directed at the underlying condition, with the goal of minimizing symptoms and preventing complications. The choice of the therapeutic agent depends on the severity of infection and the degree of host defense impairment. Medical therapy for fungal conditions falls into 3 categories, as follows: (1) topically active agents (eg, nystatin, clotrimazole, oral amphotericin B), (2) orally administered absorbable agents (eg, fluconazole, itraconazole), and (3) parenterally administered agents (eg, amphotericin B, fluconazole, flucytosine). Most patients with fungal esophagitis who are immunocompetent can be treated with a topical antifungal agent. They are virtually devoid of adverse effects and have few, if any, drug-drug interactions because they are not absorbed.
The treatment of eosinophilic esophagitis continues to evolve. Various interventions, such as complete avoidance of precipitating food allergens, esophageal dilatation, corticosteroids, cromolyn sodium, and leukotriene inhibitors, have been performed. Until the natural history of this disease is understood more fully and appropriate trials are performed, the treatment of this condition will continue to be empirical.
Antifungal agents
Topical or systemic treatment of fungal infections.
Clotrimazole (Mycelex)
Nonabsorbable imidazole. Broad-spectrum synthetic antifungal agent that inhibits growth of yeasts by altering cell membrane permeability.
Adult
Immunocompetent patients: 10 mg buccal troches dissolved 5 times/d for 1 wk
Immunocompromised patients: 100 mg vaginal tab dissolved in mouth tid
Pediatric
<3 years: Not recommended
>3 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not for treatment of systemic fungal infections; avoid contact with the eyes; if irritation or sensitivity develops, discontinue use and institute appropriate therapy; abnormal findings on LFTs and SGOT have occurred; periodically monitor LFTs in hepatic disease
Nystatin (Mycostatin)
Nonabsorbable polyene antifungal agent obtained from Streptomyces noursei. Binds to sterols in cell membrane of susceptible fungi, with resulting change in membrane permeability allowing leakage of intracellular components. Indicated for treatment of PO candidiasis.
Adult
Troche: 200,000-400,000 U dissolved PO 4-5 times/d
Susp: 400,000-600,000 U swish and swallow 4-5 times/d for 1 wk
Pediatric
Troche: Not established
Susp: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat systemic mycoses; PO irritation or sensitization may occur; GI distress may occur with large doses
Fluconazole (Diflucan)
Synthetic triazole fungistatic agent. Highly selective inhibitor of fungal cytochrome P-450 sterol C-14 alpha demethylation.
Adult
200 mg PO on day 1, then 100 mg PO qd for 2-3 wk after symptoms resolve
Alternatively, 400 mg PO on day 1, then 200 mg PO qd
Can use up to 400 mg/d
Pediatric
6 mg/kg PO on day 1, then 3 mg/kg PO qd for 3 wk; can use up to 12 mg/kg/d
Levels may increase with hydrochlorothiazide; fluconazole levels may decrease with long-term coadministration of rifampin; coadministration of fluconazole may decrease phenytoin concentrations; may increase concentrations of rifabutin, theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration; increases in cyclosporine and tacrolimus concentrations may occur when administered concurrently
Documented hypersensitivity; administration with terfenadine or cisapride
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose for renal insufficiency; monitor closely if rashes develop and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions such as AIDS or a malignancy while taking multiple concomitant medications; not recommended for nursing mothers; convenience and efficacy of single-dose regimen for treatment of vaginal yeast infections should be weighed against difficulties resulting from higher incidence of adverse reactions reported with PO fluconazole versus intravaginal agents; caution in patients taking OCPs containing ethinyl estradiol and levonorgestrel
Amphotericin B, conventional (Amphocil, Fungizone)
Binds to sterols in the cell membrane and alters permeability. Used in patients with granulocytopenia. PO route infrequently used and has no advantage over PO clotrimazole or nystatin.
Adult
0.5 mg/kg/d IV in febrile patients or patients with disseminated disease for a total dose of 1.5-2 g over 6-12 wk
Alternatively, 0.3 mg/kg/d IV for 7-10 d
Pediatric
Infants: Not established
Children: Administer as in adults
Antineoplastic agents may enhance the potential of amphotericin B for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; the risk of renal toxicity is increased with cyclosporine use
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor renal function, serum electrolytes such as magnesium and potassium, liver function, CBC count, and hemoglobin concentrations; resume the therapy at the lowest level (eg, 0.25 mg/kg) when the therapy is interrupted for more than 7 d; hypoxemia, acute dyspnea, and interstitial infiltrates may occur in patients who are neutropenic receiving leukocyte transfusions (separate time of amphotericin infusion from time of leukocyte transfusion); fever and chills are not uncommon after first few administrations of drug; rare acute reactions may include hypotension, bronchospasm, arrhythmias, and shock
Anidulafungin (Eraxis)
Antifungal agent of the echinocandin class. Inhibits synthesis of 1,3-beta-D-glucan, an essential component of fungal cell walls. Indicated to treat esophageal candidiasis, candidemia, and other forms of candidal infections (eg, intra-abdominal abscesses, peritonitis).
Adult
Candidemia or other candidal infections: 200 mg IV on day 1, decrease dose on day 2 and thereafter to 100 mg/d IV
Esophageal candidiasis: 100 mg IV on day 1, decrease dose on day 2 and thereafter to 50 mg/d IV
Do not exceed infusion rate of 1.1 mg/min
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Common adverse effects include hypokalemia, diarrhea, elevated hepatic enzyme levels, and headache; rare reports of serious hepatotoxicity; infusion-related reactions (eg, rash, urticaria, flushing, pruritus, dyspnea, hypotension) may occur, particularly with rapid infusion; following reconstitution, dilute further with D5W or NS before administration
Antiviral agents
Treat HSV or CMV viral infections. In addition to the drugs listed below, famciclovir (Famvir), a prodrug of the antiviral agent penciclovir, which is not currently recommended for treatment, may replace acyclovir in prophylaxis and treatment.
Acyclovir (Zovirax)
Synthetic purine nucleoside analog that stops replication of viral DNA. Used for HSV esophagitis.
Adult
250 mg/m2 IV q8h for 7-10 d
Pediatric
Administer as in adults
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or when using other nephrotoxic drugs
Foscarnet (Foscavir)
Organic analog of inorganic pyrophosphate that inhibits replication of HSV and CMV. Used for acyclovir-resistant cases.
Adult
Induction: 90 mg/kg IV q12h for 3-6 wk
Maintenance: 90-120 mg/kg/d IV single infusion
Pediatric
Not established
Coadministration with potentially nephrotoxic drugs (eg, aminoglycosides, amphotericin B, IV pentamidine) may increase nephrotoxicity (do not administer unless potential benefits outweigh risks); coadministration with IV pentamidine may cause hypocalcemia
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause decline in renal function; for correct dosing, obtain 24-h serum creatinine at baseline and continue to monitor (discontinue if serum creatinine <0.4 mL/min/kg); hydration may reduce nephrotoxicity; carefully monitor electrolytes (eg, calcium, magnesium); assess for electrolyte and mineral level abnormalities if mild perioral numbness, paresthesias symptoms, or seizures occur; granulocytopenia and anemia may occur (regularly monitor CBC count); infuse foscarnet solutions into veins with adequate blood flow to avoid local irritation; to avoid toxicity, do not administer by rapid or bolus IV injection
Ganciclovir (Cytovene)
Acyclic nucleoside analog that inhibits replication of herpes viruses. Active against CMV and HSV.
Adult
Induction: 5 mg/kg IV q12h for 2-3 wk
Maintenance: 6 mg/kg IV 5 times per wk
Pediatric
Administer as in adults
Concomitant administration with cytotoxic drugs such as dapsone, vinblastine, Adriamycin, pentamidine, flucytosine, vincristine, amphotericin B, trimethoprim/sulfamethoxazole combinations, or other nucleoside analogs may result in additive toxicity in bone marrow, spermatogonia, and the germinal layers of skin and GI mucosa (coadminister only if potential benefits outweigh risks); coadministration with imipenem-cilastatin may cause generalized seizures (use only if potential benefits outweigh risks); serum creatinine may increase following concurrent use of ganciclovir with either cyclosporine or amphotericin B; in the presence of probenecid, ganciclovir renal clearance is reduced; bioavailability may increase when didanosine is administered either 2 h prior to or simultaneously with ganciclovir; bioavailability of ganciclovir may decrease in the presence of zidovudine, while bioavailability of zidovudine is increased in the presence of ganciclovir
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Clinical toxicity of ganciclovir includes granulocytopenia, anemia, and thrombocytopenia; because PO ganciclovir is associated with a higher rate of CMV retinitis progression compared to the IV formulation, use only when benefits outweigh risks (advanced HIV disease); half-life and plasma/serum concentrations of ganciclovir may be increased as a result of reduced renal clearance; dosages > 6 mg/kg IV may result in increased toxicity; rapid infusions may result in increased toxicity; initially, reconstituted solutions of IV ganciclovir have a high pH (11); phlebitis or pain may occur at site of IV infusion despite further dilution in IV fluids; administration of ganciclovir should be accompanied by adequate hydration; photosensitization (ie, photoallergy, phototoxicity) may occur
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Sterapred, Orasone)
Administered in immunosuppressive doses, which may vary based on the underlying disease process. Dose is usually slowly tapered over wk to mo. Equivalent dose of methylprednisolone (Solu-Medrol) may be used instead of prednisone.
Adult
30-60 mg PO qd or divided bid/qid; taper over few wk to mo, as symptoms resolve
Literature reports a large variability in dose; generally use lowest dose that produces a clinical response
Pediatric
Not established
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use; during stress (eg, surgery, illness) stress doses of short-acting steroids are necessary
More on Esophagitis |
| Overview: Esophagitis |
| Differential Diagnoses & Workup: Esophagitis |
 Treatment & Medication: Esophagitis |
| Follow-up: Esophagitis |
| Multimedia: Esophagitis |
| References |
| « Previous Page | 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
