History
The history findings vary based on the type of esophagitis. Esophageal food impaction can be the initial presentation of proton pump inhibitor (PPI)-responsive eosinophilic esophagitis. [49]
Symptoms of reflux esophagitis
The most common complaint in patients with esophagitis is heartburn (dyspepsia), a burning sensation in the midchest caused by the contact of stomach acid with the esophageal mucosa. Symptoms often are maximal while the person is supine, bending over, or wearing tight clothing or after the person has eaten a large meal. The patient may complain of water brash, a bitter taste of refluxed gastric contents often associated with heartburn. [1]
The American College of Gastroenterology (ACG) published updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) in 2013. [50] According to the ACG guidelines, regurgitation and heartburn, separately or in conjunction, are the symptoms most specific for GERD. For patients with symptoms of uncomplicated GERD, the diagnosis of GERD may be assumed and empiric PPI therapy begun. For patients who show signs of GERD complications or other illness or who do not respond to therapy, further diagnostic testing should be considered.
Other common symptoms of esophagitis include upper abdominal discomfort, nausea, bloating, and fullness. Less common symptoms of esophagitis include dysphagia, odynophagia, cough, hoarseness, wheezing, and hematemesis.
The patient may experience chest pain indistinguishable from that of coronary artery disease. Pain is often midsternal, with radiation to the neck or arm, and may be associated with shortness of breath and diaphoresis. Chest pain may be relieved with nitrates if esophageal spasm is involved, further confounding the diagnostic evaluation.
Infants with gastroesophageal reflux are at a greater risk of aspiration. Symptoms include weight loss, regurgitation, excessive crying, backache, respiratory distress, and apnea.
Symptoms of infectious esophagitis
Infectious esophagitis is primarily seen in patients who are immunocompromised. The most common causes of infectious esophagitis are fungal (Candida species) and viral (herpes simplex virus and cytomegalovirus [CMV]). 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:
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Onset of difficult or painful swallowing (ie, dysphagia, odynophagia)
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Heartburn
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Retrosternal discomfort or pain
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Nausea, vomiting
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Fever, sepsis
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Abdominal pain
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Epigastric pain
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Hematemesis (occasionally)
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Anorexia, weight loss (depends on chronicity and severity of underlying illness)
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Cough
Candida esophagitis is usually manifested clinically by dysphagia and/or odynophagia in a patient with one or more predisposing factors for the condition. Symptoms are variable in severity, ranging from mild difficulty in swallowing to such intense odynophagia that the patient is unable to eat or swallow saliva. Other patients may present with chest pain or gastrointestinal (GI) tract bleeding; occasionally, patients are asymptomatic.
Herpes esophagitis is most commonly seen in immunocompromised patients with acquired immunodeficiency syndrome (AIDS), an underlying malignancy, or a debilitating illness or in patients who have been treated with radiation, steroids, or chemotherapy. [51] However, it occasionally occurs as an acute self-limiting disease in otherwise healthy patients who have no underlying immunologic problems. Patients with herpes esophagitis typically present with an acute onset of severe odynophagia. Other presenting findings include dysphagia, chest pain, and upper GI tract bleeding.
CMV esophagitis is usually manifested by the development of severe odynophagia, dysphagia, or both, in patients with AIDS. In affected individuals, evidence of CMV infection may be present in other organs or tissues, such as the retina, liver, and colon. Occasionally, odynophagia may be so severe that the patients develop sitophobia (fear of eating), and parenteral alimentation is required.
Patients with human immunodeficiency virus ulcers typically present with acute onset of severe odynophagia, dysphagia, or both. If the ulcers develop at the time of seroconversion, a characteristic maculopapular rash may be seen on the upper half of the body.
Tuberculous esophagitis occurs primarily in patients with advanced pulmonary or mediastinal tuberculosis or in immunocompromised patients who have disseminated tuberculosis or other mycobacterial diseases.
Physical Examination
The physical examination usually is not helpful in confirming the diagnosis of uncomplicated esophagitis. However, the examination may reveal other potential sources of chest or abdominal pain.
Perform a rectal examination (eg, stool guaiac) to identify the presence of occult bleeding.
Examine the oral cavity (for thrush or ulcers). Oropharyngeal candidiasis is commonly associated with esophageal candidiasis; therefore, the presence of oral thrush may be helpful in suggesting the diagnosis of Candida esophagitis in the appropriate clinical setting. Nevertheless, only 50%-75% of patients with Candida esophagitis have oropharyngeal disease, and some patients with oropharyngeal candidiasis and dysphagia are found to have other types of esophagitis; therefore, the correct diagnosis cannot always be suggested on the basis of clinical presentation.
Look for signs of immunosuppression and skin signs of systemic disease (eg, telangiectasias and sclerodactyly in scleroderma).
Although the presence of herpes labialis (cold sores) or herpetic lesions of the oropharynx should suggest the presence of herpetic esophagitis in the appropriate clinical setting, most patients have no concurrent oropharyngeal herpetic lesions. Moreover, some patients with odynophagia and oral herpes eventually are found to have Candida esophagitis. Therefore, the presence of other herpetic lesions is not accurately predictive of herpes esophagitis in patients with odynophagia. There are rare reports of concomitant herpetic and candidal esophagitis. [29]
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Esophagitis. Location of fungal and viral infections in ulcers.
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Peptic esophagitis. A rapid urease test (RUT) was performed on the esophageal biopsy sample. The result was positive for Helicobacter pylori.
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Corrosive esophagitis. This is a vinegar-induced esophageal burn. The patient had a fish bone in her throat. She ingested vinegar in an attempt to dissolve the fish bone but to no avail; this led to corrosive esophagitis.
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Infectious esophagitis. Candida esophagitis. Double-contrast esophagram shows linear plaquelike lesions in the esophagus, with normal intervening mucosa.
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Infectious esophagitis. Two examples of advanced Candida esophagitis demonstrate a shaggy esophagus. In both images, the double-contrast esophagram shows a grossly irregular esophageal contour due to innumerable plaques and pseudomembranes, with the trapping of barium between lesions. Patients with this fulminant form of esophageal candidiasis are almost always found to have acquired immunodeficiency syndrome (AIDS).
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Infectious esophagitis. Candida esophagitis with a foamy esophagus. This patient has a dilated esophagus with beaklike narrowing (arrow) at the gastroesophageal junction as a result of long-standing achalasia. Innumerable tiny bubbles are layering out in the barium column due to infection by the yeast form of candidiasis.
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Infectious esophagitis. Herpes esophagitis. Double-contrast esophagram shows small, discrete ulcers (arrows) in the mid esophagus on a normal background mucosa. Note the radiolucent mounds of edema surrounding the ulcers. In the appropriate clinical setting, this appearance is highly suggestive of herpes esophagitis, since ulceration in candidiasis almost always occurs on a background of diffuse plaque formation.
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Infectious esophagitis. Cytomegalovirus esophagitis in a patient with acquired immunodeficiency syndrome (AIDS). Double-contrast esophagram shows a large, flat ulcer in profile (large arrows) in the mid esophagus with a cluster of small satellite ulcers (small arrows). Because HIV esophagitis may produce identical radiographic findings, endoscopy is required to confirm the presence of cytomegalovirus before patients are treated.
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Infectious esophagitis. Two examples of giant human immunodeficiency virus (HIV) esophageal ulcers (arrows) in patients with acquired immunodeficiency syndrome (AIDS). In A, the ulcer is seen in profile, whereas in B, the ulcer is seen en face. Endoscopy is required to exclude cytomegalovirus as the cause of this finding before treating patients.
