Esophagitis Treatment & Management

Treatment begins with hemodynamic stabilization and pain management. Subsequent therapy depends on the cause of the esophagitis and on any complications present. Surgery (fundoplication) is sometimes indicated in patients with severe pain who fail to respond to medical management.

Go to Pediatric Esophagitis for complete information on this topic.

Initial care is directed toward complications (eg, bleeding, perforation) that require hemodynamic stabilization. Admit the patient when significant bleeding, perforation, obstruction, or volume depletion occurs.

Chest pain of esophageal origin cannot be differentiated accurately from chest pain associated with coronary artery disease. Therefore, prehospital protocols should be followed for management of chest pain potentially caused by coronary artery disease. When the cause of the pain is uncertain, oxygen is generally indicated.

Previously, histamine-2 receptor antagonist (H2RA) therapy was recommended as the initial treatment for esophagitis associated with gastroesophageal reflux disease (GERD); however, newer evidence in cost-effectiveness analysis and symptomatic relief suggests proton pump inhibitors (PPIs) (omeprazole 20 mg daily, pantoprazole 40 mg daily, or lansoprazole 30 mg daily for 4-8 wk) to be superior to ranitidine, cimetidine, and placebo.

The 2005 ACG GERD guidelines recommend PPIs as more effective than H2RAs for GERD based on highest-level evidence. The guidelines state that greater percentage of patients with reflux esophagitis healed when treated with PPIs than with H2RA.^[39]

Cisapride, a gastroprokinetic agent, and sucralfate, a coating agent, are less effective but may be useful in selected patients or as second-line agents. Cisapride is only available through an investigational limited-access program because of its potential for risk of serious cardiac arrhythmias and death.

Some authorities suggest PPIs and histamine-2 receptor antagonists for patients with ulcerlike-dominant symptoms (eg, nocturnal symptoms, relief with food) and gastroprokinetic agents for patients with dysmotility dominant symptoms (eg, nausea, bloating).

Although no consensus on treatment choice exists, prescribing for 2-4 weeks with reassessment is reasonable. Some patients with relapse may require long-term maintenance therapy.

According to the 2005 ACG guidelines, patients whose GERD symptoms could not be controlled with antacids and lifestyle modifications, but were relieved by PPIs, are likely to require long-term, even life-long, maintenance therapy.^[39]

Treatment of Infectious Esophagitis

Treatment is directed at the underlying cause. The goal of medical care is to treat the underlying cause and minimize morbidity.

Fungal esophagitis

Medical therapy for fungal conditions falls into 3 categories, as follows:

• Topically active agents include nystatin, clotrimazole, and oral amphotericin B
• Orally administered absorbable agents include fluconazole and itraconazole^[43]
• Parenterally administered agents include amphotericin B, fluconazole, and flucytosine

The choice of agent depends on the severity of infection and degree of host defense impairment. 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.

In a study at the digestive endoscopy unit of a Brazilian hospital, Wilheim et al found the incidence of esophageal candidiasis to be low, determining that 40 out of 2,672 patients (1.5%) who underwent esophagogastroduodenoscopy had endoscopic findings compatible with the disorder.^[43] Just over half of these 40 patients were male, and 65% of them were inpatients. Of the 90% of patients in whom associated diseases were identified, 21 (52.5%) were infected with HIV. Among the 21 patients under age 50 years, 82.6% were HIV positive.

Endoscopy revealed severe forms of esophagitis in 50% of patients in the Wilheim study with a CD4 count below 200 cells/µL. Candida species other than Candida albicans were isolated in 22.7% and 45% of HIV-positive and HIV-negative patients, respectively. Six patient Candida samples were found to be fluconazole-resistant, while 2 samples had dose-dependent susceptibility to this agent.

Herpes esophagitis

Herpes simplex virus (HSV) esophagitis diagnosed at endoscopy is typically treated with acyclovir, foscarnet (for acyclovir-resistant cases), or famciclovir (an acyclovir analog).

Cytomegalovirus esophagitis

Cytomegalovirus (CMV) esophagitis is treated differently from HIV esophagitis. However, these 2 entities cannot be reliably differentiated on the basis of the clinical and radiographic findings; thus, endoscopy is required for a definitive diagnosis before patients are treated. When multiple esophageal biopsy specimens, brushings, and/or viral cultures are obtained, endoscopy has a sensitivity of greater than 95% in the diagnosis of CMV esophagitis.

CMV esophagitis is usually treated with ganciclovir and foscarnet, which are potent antiviral agents that have significant bone marrow and renal toxicities, respectively.

Go to Cytomegalovirus Esophagitis for complete information on this topic.

HIV esophagitis

In contrast to CMV esophagitis, HIV esophagitis is treated with oral corticosteroid therapy, usually for longer than 1 month, in conjunction with antiretroviral therapy for HIV.

Varicella-zoster virus esophagitis

Varicella-zoster virus (VZV) esophagitis is typically with acyclovir, famciclovir, or foscarnet (for acyclovir-resistant cases).

Epstein-Barr virus esophagitis

Epstein-Barr virus (EBV) esophagitis is treated with acyclovir. Long-term maintenance therapy may be required to suppress oral hairy leukoplakia.

Human papillomavirus esophagitis

Human papillomavirus (HPV) esophagitis is often asymptomatic; thus, no treatment is usually needed. Systemic interferon alfa, bleomycin, and etoposide have been used, with variable results.

Mycobacterium tuberculosis esophagitis

Standard antituberculous therapy is used for immunocompetent hosts.

Bacterial esophagitis

Infection by 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.

Bacterial esophagitis is treated with broad-spectrum beta-lactam antibiotics, usually in combination with an aminoglycoside. Adjustments are based on response and culture results.

Treatment of nonreflux, noninfectious esophagitis depends on the underlying condition.

Behçet disease esophagitis

Treatment consists of corticosteroids for serious inflammation and chlorambucil or azathioprine for long-term therapy.

Graft versus host disease esophagitis

This condition is treated with dilation and antireflux measures and the use of prednisone, cyclosporine, azathioprine, and thalidomide.

Inflammatory bowel disease esophagitis

Esophagitis associated with inflammatory bowel disease is treated by means of corticosteroid therapy for inflammatory lesions and dilation for strictures. Surgery may be needed to treat fistulas and strictures.

Eosinophilic esophagitis

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.

One study suggests that a 15-day course of treatment with budesonide is well tolerated with no serious side effects and is highly effective for remission in adolescent and adult patients with eosinophilic esophagitis.^[44]

Metastatic cancer esophagitis

This condition is treated by means of radiation therapy and palliation with stents.

Treatment of esophagitis linked to medications or radiation therapy depends on the underlying cause.

Medication-related esophagitis (pill esophagitis)

The offending medication should be stopped. Control of acid reflux may accelerate healing. Patients should take medication with plenty of water while sitting in the upright position.

Radiation and chemoradiation esophagitis

Healing may not occur for several months after cessation of radiation therapy. Treatment is with viscous lidocaine and sucralfate. Stricture formation is a common complication and may require endoscopy for dilation.

No particular diet restrictions are necessary; however, if the patient has odynophagia or is unable to consume calories orally, then gastric feeding or parenteral feeding may be needed. No limitations on patient physical activity are necessary.

Consult a gastroenterologist to facilitate diagnosis and treatment. A gastroenterologist should also be consulted for cases involving moderate-to-severe bleeding, perforation, or suspected obstruction. 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.

The patient should receive follow-up care from his or her primary care provider. Refer the patient for endoscopy in the presence of suspected complications such as strictures, minor bleeding not requiring admission, and failure of medical therapy.

Medical, surgical, and endoscopic treatments are available for patients with erosive esophagitis caused by chronic GERD. The Agency for Healthcare Research and Quality has produced a comparative review of the efficacy and safety of these treatments.^[45]