Approach Considerations
Treatment begins with hemodynamic stabilization and pain management. 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 accurately distinguished from chest pain associated with coronary artery disease (CAD). Therefore, prehospital protocols should be followed for the management of chest pain potentially caused by CAD. When the cause of the pain is uncertain, oxygen is generally indicated.
Therapy after initial management depends on the cause of the esophagitis and on any complications present. Surgery (fundoplication) is sometimes indicated in patients with severe symptoms who fail to respond to medical management (eg, some patients with esophagitis and chronic gastroesophageal reflux disease [GERD]). [54]
In general, no particular dietary 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. (See also Diet.) No limitations on patient physical activity are necessary.
See Pediatric Esophagitis for complete information on this topic.
Reflux Esophagitis
Previously, histamine-2 receptor antagonist (H2RA) therapy was recommended as the initial treatment for esophagitis associated with gastroesophageal reflux disease (GERD); however, subsequent studies of cost-effectiveness and symptomatic relief suggested that proton pump inhibitors (PPIs) (eg, omeprazole 20 mg/day, pantoprazole 40 mg/day, or lansoprazole 30 mg/day for 4-8 weeks) are superior to ranitidine, cimetidine, and placebo.
The 2013 GERD guidelines from the American College of Gastroenterology (ACG) emphasize that PPIs are more effective than H2RAs for GERD on the basis of the highest-level evidence. [50] No significant differences among the various PPIs currently available were noted.
Cisapride, a gastroprokinetic agent, and sucralfate, a coating agent, are less effective but may be useful in selected patients or as second-line agents, usually for combination therapy. Cisapride is only available through an investigational limited-access program because of its potential for risk of serious cardiac arrhythmias and death.
Some authorities recommend PPIs and H2RAs 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 2013 ACG guidelines, GERD patients whose symptoms continue after discontinuance of PPI therapy and those with complications such as erosive esophagitis and Barrett esophagus are likely to require long-term, even life-long, maintenance therapy. [50] For patients who require long-term PPI therapy, it should be administered at the lowest effective dose, including on-demand or intermittent therapy.
Infectious Esophagitis
Treatment of infectious esophagitis is based on the patient's immune status, disease severity, and risk of complications. [7] The goal of medical care is to treat the underlying cause and minimize morbidity.
Fungal esophagitis
Medical therapy for fungal conditions falls into the following three categories:
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Topically active agents include nystatin, clotrimazole, and oral amphotericin B
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Orally administered absorbable agents include fluconazole and itraconazole [55]
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Parenterally administered agents include amphotericin B, fluconazole, and flucytosine
The choice of agent depends on the severity of infection and the 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 these agents 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 of 2,672 patients (1.5%) who underwent esophagogastroduodenoscopy (EGD) had endoscopic findings compatible with the disorder. [55] 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 human immunodeficiency virus (HIV). Among the 21 patients younger than 50 years, 82.6% were HIV-positive.
In this study, endoscopy revealed severe forms of esophagitis in 50% of patients 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. In six patients, the Candida samples were found to be fluconazole-resistant, whereas two 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 two 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.
See 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 treated 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 in 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.
Esophagitis Associated with Systemic Illnesses
Treatment of nonreflux, noninfectious esophagitis depends on the underlying conditions.
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 (Crohn 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 (see Diet), esophageal dilatation, corticosteroids, cromolyn sodium, and leukotriene inhibitors, have been employed. Until the natural history of this disease is understood more fully and appropriate trials are performed, treatment of this condition will continue to be empiric.
In a 2014 review of the clinical, endoscopic, and histologic features of eosinophilic esophagitis in adults and children, Dellon and Liacouras noted that this condition can be treated with topical corticosteroids or dietary strategies. [56] Endoscopic dilation is an important tool for the treatment of fibrostenotic complications. Unresolved issues include phenotypes, optimal treatment end points, the role of maintenance therapy, and treatment of refractory disease. Ideally, eosinophilic esophagitis is managed by a multidisciplinary team comprised of gastroenterologists, allergists, pathologists, and dietitians.
A study by Straumann et al suggested 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. [57]
Rokkas et al conducted a network meta-anaylsis that included 1011 patients and 15 therapeutic interventions. They concluded that budesonide 1 mg orodispersible tablet twice daily was the most effective treatment for eosinophilic esophagitis. [58]
In a study by Rothenberg et al, QAX576, a monoclonal antibody to interleukin (IL)-13, was found to be efficacious in the treatment of patients with eosinophilic esophagitis refractory to proton-pump inhibitors (PPIs). [59] Intravenous QAX576 or placebo was given at weeks 0, 4, and 8, and patients were followed for 6 months. Efficacy was to be declared if the lower 90% confidence limit for the proportion of responders (those with a greater than 75% decrease in peak eosinophil counts at week 12) on QAX576 was 35% or greater.
Twenty-three patients completed this study up to week 12; 18 continued to the end of the study. [59] For the proximal and distal esophageal biopsies combined, the responder rate was 40.0% for QAX576, compared with 12.5% for placebo. QAX576 was well tolerated. Although the primary end point was not met, the mean esophageal eosinophil count decreased by 60% with QAX576 versus a 23% increase with placebo. The decrease was sustained for up to 6 months.
Metastatic cancer esophagitis
This condition is treated by means of radiation therapy and palliation with stents.
Esophagitis Associated with Pharmacologic or Other Therapy
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.
Diet
A diet eliminating six food groups (six-food elimination diet [SFED]) that are likely to trigger allergies may help to ease the symptoms of eosinophilic esophagitis in adults, according to a study of 67 patients with active disease. [60, 61] The six food groups (cereals, milk, eggs, fish/seafood, legumes/peanuts, and soy) were eliminated and then reintroduced sequentially, one at a time. [6, 9]
Of the 67 patients in this study, 49 (73.1%) exhibited significant drops in peak eosinophil counts before foods were reintroduced. [60, 61] In all, 35.71% of the patients had one food trigger, 30.95% had two, and 33.3% had three or more. The most common food triggers, in descending order of frequency, were cow milk, wheat, eggs, and legumes. Patients who continued to avoid the allergy-triggering foods maintained a histopathologic and clinical remission for as long as 3 years.
In a cost utility analysis that compared the SFED with topical corticosteroids for first-line therapy of eosinophilic esophagitis, Cotton et al noted that although both therapies had similar efficacy, the six-food elimination diet was less expensive and more cost effective overall. [62]
In a study that evaluated patient-related costs for the SFED, Asher Wolf et al found that compared to an unrestricted diet, the cost of the SFED was higher ($92.54 vs $79.84, respectively; P = 0.0001) at a standard grocery store, and the SFED required the purchase of a higher proportion of items at another store (32% vs 3%, respectively; P = 0.0001). [63] The costs and number of items requiring a trip to a second store for both diets were similar when shopping at specialty grocery stores.
Consultations
Consult a gastroenterologist to facilitate the 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.
Long-Term Monitoring
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 gastroesophageal reflux disease. The Agency for Healthcare Research and Quality has produced a comparative review of the efficacy and safety of these treatments. [64]
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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.
