eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Esophagitis: Differential Diagnoses & Workup

Author: Jessica Wen, MD, Clinical Fellow, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia
Coauthor(s): Andrew S Chu, MD, Medical Director, CHOP Connection at Grand View Hospital, Children's Hospital of Philadelphia; Clinical Assistant Professor, Division of General Pediatrics, Department of Pediatrics, University of Pennsylvania School of Medicine; Maria Rebello Mascarenhas, MBBS, Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Children's Hospital of Philadelphia; Vera De Matos, MD, Fellow in Pediatric Gastroenterology, The Children's Hospital of Philadelphia, University of Pennsylvania
Contributor Information and Disclosures

Updated: Mar 5, 2008

Differential Diagnoses

Burns, Chemical
Herpes Simplex Virus Infection
Candidiasis
Peptic Ulcer Disease
Cytomegalovirus Infection
Sandifer Syndrome
Esophageal Stricture
Torticollis
Functional Abdominal Pain
Gastroesophageal Reflux
Gastrointestinal Foreign Bodies

Other Problems to Be Considered

Eosinophilic gastroenteropathy
GI bleeding
Radiation therapy complications

Workup

Laboratory Studies

  • Few helpful diagnostic laboratory studies for esophagitis are available.
  • A CBC count may reveal anemia (usually iron deficiency with blood loss) or a nonspecific leukocytosis. A peripheral eosinophilia may be observed in patients with eosinophilic esophagitis.
  • Erythrocyte sedimentation rate, C-reactive protein level, albumin level, platelet count. Enzyme-linked immunosorbent assays (ELISAs), acute/convalescent titers, and polymerase chain reaction (PCR) for viral etiologies may be of benefit, although often not in the acute management.
  • Serum albumin levels may be decreased in patients with corrosive esophagitis or CMV infection.
  • Stool sample findings may be heme positive.

Imaging Studies

  • Plain radiography: An increased retrotracheal space may appear on lateral chest radiography with paraesophageal infections or abscesses. Chest radiography may reveal evidence of aspiration pneumonia following a corrosive ingestion.
  • Barium studies
    • An upper GI study is helpful in defining any anatomic abnormalities such as esophageal strictures, gastric outlet obstruction, pyloric stenosis, or intestinal malrotation. Esophageal motility abnormalities can be revealed with this examination. An upper GI study should be considered in all patients with persistent emesis and in whom esophagitis is suspected. Additionally, a barium swallow test can be performed to demonstrate swallowing abnormalities. These studies are not helpful in diagnosing gastroesophageal reflux (GER).
    • Performing a double-contrast upper GI study in older compliant children may be more sensitive. Mucosal irregularities, ulcers, nodules, plaques, and cobblestoning may be observed. Following a caustic ingestion, mucosal edema, dilatation, atony, or strictures are visualized.
    • An upper GI study may produce normal results even with underlying pathology or if lack of patient cooperation leads to the performance of a suboptimal study.
  • Gastroesophageal scintigraphy: Gastroesophageal scintigraphy (milk scan) can be useful in revealing the gastric-emptying rate and GER that leads to pulmonary aspiration but is not specific for esophagitis.
  • Esophageal pH probe monitoring: This can be used to document the severity of acid GER on the day of the study but does not necessarily indicate that esophagitis is present.
  • Intraluminal impedance: Findings from this study document nonacid GER that would otherwise be missed with esophageal pH probe.
  • CT scanning: This may be useful for visualizing paraesophageal abscesses that may extend into the esophagus and is also useful in evaluating perforations.
  • Esophageal manometry: This study can help clarify a differential diagnosis, although it is not usually performed in the evaluation of esophagitis.

Procedures

Esophagogastroduodenoscopy (EGD) allows more definitive visualization of the esophageal mucosa. Biopsy samples are always obtained to look for histologic confirmation; in fact, the lower esophageal tract is well known as an area in which discrepancies between endoscopic and histologic findings are often found. If needed, brushings and cultures can be obtained. Therapeutic procedures such as dilatation of esophageal strictures can also be performed.

  • In eosinophilic esophagitis, various patterns of morphological alterations are described upon endoscopy, including furrowing of the mucosa and mucosal rings. Typically, neither the gastric nor the duodenal mucosa is concomitantly involved.
  • With infectious esophagitis in immunocompromised patients, such as children with cancer, EGD with biopsy may be a valuable tool in helping to treat esophagitis in children with fever. Biopsy is the most sensitive and accurate method in diagnosing fungal esophagitis.
  • Following a corrosive ingestion, endoscopy should usually be performed within 24-48 hours in all patients. This helps to determine the degree of mucosal burns and ulcerations and the risk of complications of the esophagus, stomach, and duodenum. Late-forming ulcers and fibrin deposits may not be observed if endoscopy is performed in the first 12 hours. A string can be placed through the endoscope into the esophagus and can be left in place to help with subsequent dilatations by the surgeons.
  • An earlier procedure allows assessment of the extent of injury and burns and possible perforations. Circumferential ulcers and mucosal sloughing indicate greater severity.

Histologic Findings

  • Reflux esophagitis
    • The following 3 types of histologic changes occur in reflux esophagitis:
      • Intraepithelial infiltration of inflammatory cells (small number of eosinophils, lymphocytes and neutrophils, and squiggle cells)
      • Epithelial alterations (basal cell hyperplasia, basal cell spongiosis, abnormal nuclei and increased mitosis, balloon cells)
      • Changes in the lamina propria (elongation and increased number of papillae and vascular dilatation of papillae)
    • Metaplasia of squamous epithelium to columnar epithelium or Barrett esophagus can occur. This pathology is rare in the pediatric population compared with adult populations.
  • Allergic esophagitis or eosinophilic esophagitis: Histologic changes in allergic or eosinophilic esophagitis are similar to those seen in reflux esophagitis, but the eosinophilia is more severe, with 20 or more eosinophils per high-magnification microscopic field. In some cases, small microabscesses of eosinophils are present, and the inflammatory lesions can extend into the muscular layer of the esophagus.
  • Candidal esophagitis: Erythema, friability, and adherent white plaques that cover the mucosa are seen macroscopically in candidal esophagitis. The plaques are composed of acute inflammatory exudate mixed with necrotic debris, pseudohyphae, and budding yeast. Because Candida species can often be found in the esophagus without clinical significance, diagnosis of candidal esophagitis depends on the presence of squamous epithelium with invading hyphal forms. Invasive candidiasis can produce transmural inflammation, necrosis, and possible perforation.
  • HSV esophagitis: Shallow ulcers are the typical lesions of HSV esophagitis. An acute, nonspecific inflammatory exudate covers the ulcer. Biopsy samples collected from around the ulcer may reveal a viral cytopathic effect in the squamous epithelium (nuclei with clear appearance and condensed chromatin at the periphery) or aggregates of macrophages around herpetic ulcers.
  • CMV esophagitis: The viral cytopathic effect of CMV esophagitis is seen in the stromal elements, endothelium, and submucosal glandular epithelium rather than in the squamous epithelium. Therefore, biopsy samples taken from the base of the ulcer can be more informative than those taken from around the ulcer.
  • Corrosive esophagitis: This type of esophagitis may reveal polymorphonuclear cell infiltration, vessel thrombosis, bacterial invasion, and granulation tissue following second- and third-degree burns. Fibrous tissue, collagen deposition, and stricture formation may occur after 2 weeks.

More on Esophagitis

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

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Keywords

esophagitis, inflammation of esophagus, esophagus inflammation, gastroesophageal reflux, GER, corrosive ingestion, reflux esophagitis, peptic esophagitis, corrosive esophagitis, caustic esophagitis, eosinophilic esophagitis, radiation esophagitis, Barrett esophagus, candidal esophagitis, Sandifer syndrome, gastroesophageal reflux disease, GERD, lower esophageal sphincter, LES, EE, esophagogastroduodenoscopy, EGD, pediatric esophagitis, acid reflux, food allergy, chemical esophagitis, infectious esophagitis, acid GER, nonacid GER, poison ingestion, household cleaner ingestion, accidental ingestion, herpes simplex virus, HSV, cytomegalovirus, CMV, allergic esophagitis, Nissen fundoplication, histamine 2–receptor antagonist, prokinetic agent, proton pump inhibitor

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Contributor Information and Disclosures

Author

Jessica Wen, MD, Clinical Fellow, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia
Jessica Wen, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, American Medical Association, and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew S Chu, MD, Medical Director, CHOP Connection at Grand View Hospital, Children's Hospital of Philadelphia; Clinical Assistant Professor, Division of General Pediatrics, Department of Pediatrics, University of Pennsylvania School of Medicine
Andrew S Chu, MD is a member of the following medical societies: American Academy of Pediatrics and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Maria Rebello Mascarenhas, MBBS, Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Children's Hospital of Philadelphia
Maria Rebello Mascarenhas, MBBS is a member of the following medical societies: American Gastroenterological Association, American Society for Parenteral and Enteral Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Vera De Matos, MD, Fellow in Pediatric Gastroenterology, The Children's Hospital of Philadelphia, University of Pennsylvania
Vera De Matos, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Medical Editor

Jayant Deodhar, MD, Associate Professor in Pediatrics, BJ Medical College, India; Honorary Consultant, Departments of Pediatrics and Neonatology, King Edward Memorial Hospital, India
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Stefano Guandalini, MD, Director, University of Chicago Celiac Disease Program, Section Chief of Gastroenterology, Hepatology and Nutrition; Professor, Department of Pediatrics, University of Chicago Comer Children's Hospital
Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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