Pediatric Esophagitis Clinical Presentation

Reflux (peptic) esophagitis

Typically, emesis is effortless and is accompanied by frequent regurgitation in infants. Less commonly, however, emesis may be forceful and projectile. Hematemesis may also be observed. Hiccoughs that last a long time and hard swallows are subtle signs of gastroesophageal reflux disease (GERD) in infants and young children.

Nonspecific signs such as crying, irritability, sleep or feeding problems, arching of the back, and colic may suggest esophageal pain in infants. Infants may also demonstrate head tilting that can mimic torticollis, neck cocking, and opisthotonic posturing with arching of the back (Sandifer syndrome) or other neurobehavioral manifestations.

Apnea, chronic respiratory illnesses (pneumonia, wheezing, stridor), and asthma exacerbation may be associated with chronic GERD. Food aversion and failure to thrive or weight loss are frequent manifestations. Anemia due to iron deficiency may result from occult blood loss.

Abdominal pain, dysphagia, heartburn, and chest or epigastric pain may occur in older children and adolescents.

Corrosive (caustic) esophagitis

Coughing, crying, and vomiting following ingestion may be initial symptoms of corrosive esophagitis. Dysphagia, refusal to drink, and mouth or chest pain with drooling and salivation may follow. Respiratory distress and stridor can result from airway obstruction and glottic edema.

To help determine the potential for morbidity, always try to obtain the original container or exact product name of the caustic substance ingested. Do not be falsely reassured by the quantity of the ingestion. Significant burns have followed minimal exposures, such as licking the bottle cap of a container that holds an alkali and eating from an unwashed spoon that had been used to measure liquid lye.

Dysphagia and chest pain may occur after ingestion of pill forms of antibiotics (eg, doxycycline, clindamycin, tetracycline) or medications including ferrous sulphate, potassium chloride, quinidine, and anti-inflammatory agents.

Infectious esophagitis

Mouth ulcers, thrush, fever blisters, or skin lesions (viral) may be the presenting concerns. Odynodysphagia, refusal to drink, and dysphagia may occur, especially with viral and fungal esophagitis. Fever, dyspnea, or atypical chest pain may also occur.

In immunocompetent patients, herpes simplex virus (HSV) infection can present as fever, odynodysphagia, and acute-onset retrosternal pain. Oropharyngeal lesions are usually absent. Rarely, HSV, cytomegalovirus (CMV), and HIV can cause an asymptomatic esophagitis.

Eosinophilic esophagitis

Eosinophilic esophagitis can occur at any age. In infants and young children, eosinophilic esophagitis presents with symptoms similar to those of GERD (including regurgitation, irritability, food refusal, and failure to thrive in infants) but fails to respond to aggressive antireflux therapy. Dysphagia, food impaction, and chest pain may occur in older children and adolescents.

Eosinophilic esophagitis is often seen in patients with atopy who have asthma, eczema, or chronic rhinitis or in those who have a family history of atopic disease.

Radiation esophagitis

Retrosternal chest pain and dysphagia occur. Strictures that present as dysphagia can occur up to 10 years after the treatment.

Assess vital signs. Patients may exhibit tachypnea, increased work of breathing, tachycardia, fever, or hypoxia, especially following caustic ingestions.

Carefully examine the oropharynx for thrush (suggestive of candidal esophagitis), dental enamel and dentine erosions (suggestive of acid gastroesophageal reflux [GER]), burns, erythema, plaques, and ulcerations. Oral candidiasis is not predictive of esophageal involvement, except in the immunocompromised child. Nevertheless, extensive esophagitis may be present without oral candidiasis in immunocompromised patients.^[6]

Immunosuppressed patients with infectious esophagitis caused by herpes simplex (HSV) typically have vesicular lesions in the oropharynx. However, immunocompetent patients with esophagitis from HSV—the only viral pathogen that commonly causes esophagitis in immunocompetent hosts—usually have no oropharyngeal lesions.

Oral findings may also be absent in corrosive esophagitis, even in patients with more severe esophageal or gastric burns. In one study of patients with a history of caustic ingestion, almost 50% of patients with no oral lesions had esophageal burns, whereas only slightly more than 50% of patients with oral lesions also had esophageal lesions.

Examination of the skin may reveal eczema. The respiratory examination may reveal signs of asthma or reactive airway disease.

In newborns who have esophagitis as a complication of congenital infections, intrauterine growth retardation, lymphadenopathy, hepatitis, organomegaly, and central nervous system abnormalities can be observed.

Check stools for heme positivity in any child with possible esophagitis.

Bleeding or upper airway obstruction with hemodynamic compromise and perforation of the esophagus or stomach are the most significant immediate complications. Over the long term, all types of esophagitis can be complicated by the development of strictures. After radiation therapy, strictures can occur within 1-10 years after the initial treatment.

Apnea, chronic respiratory illnesses (including asthma), and failure to thrive are not rare complications of reflux esophagitis. GERD can be complicated by Barrett esophagus and, subsequently, by adenocarcinoma, although these 2 conditions are rare in the pediatric population. Enamel and dentine erosions can complicate GERD.

The long-term complications of corrosive esophagitis include perforation, secondary bacterial infections (aspiration pneumonia, peritonitis, mediastinitis, sepsis), altered motility, and obstruction with stricture formation.

Complications of infectious esophagitis include abnormal motility, obstruction, ulceration, perforation, fistula formation, secondary bacterial infections, and hemorrhage.