Approach Considerations
Specific treatment for esophagitis varies with the etiology. Symptomatic treatment may include antacids for mild reflux esophagitis or viral esophagitis in the immunocompetent host. Hospitalization is required if patients have significant bleeding, hemodynamic compromise, obstruction, perforation, or respiratory distress or are unable to feed themselves. In particular, be certain to have a low threshold for admitting a child to the hospital after any caustic ingestion.
Treatment of Reflux (Peptic) Esophagitis
For mild gastroesophageal reflux (GER), prone and elevated head positioning, feeding recommendations (eg, thickening formula, providing smaller and more frequent feedings, fasting for at least 2 h before sleeping in older children), and other conservative reflux measures (eg, eliminating tobacco smoke exposure) may be used.
Although gastroesophageal reflux disease (GERD) may be initially treated with histamine-2 (H2)–receptor antagonists, tachyphylaxis quickly develops. Proton pump inhibitors (PPIs) should be used when reflux esophagitis is diagnosed because the effect of PPIs is more sustained and powerful. [29] A study of healthy children found that erosive esophagitis treated with adequate doses of PPIs for 3 months has a low relapse rate and does not require maintenance with PPIs or H2 -blocker therapy. [30, 31] Emerging research has shown associations of long-term use of acid blocking medications with adverse events in children including increased incidence of necrotizing enterocolitis in preterm infants and increased risk of infections. These infections include clostridium difficile colitis, candida esophagitis, and community-acquired pneumonia. Clearly, risks and benefits of these medications need to be considered alongside the decision to prescribe. [32, 33, 34]
In severe cases of reflux esophagitis that are unresponsive to aggressive medical management, consider surgical referral for Nissen fundoplication. With the availability of PPIs, this surgical indication is now restricted to less than 1% of all cases. Patients with associated delay in gastric emptying may require a pyloroplasty. A gastrostomy or jejunostomy tube may be placed to assist with feeding.
Treatment of Corrosive (Caustic) Esophagitis
For corrosive esophagitis with alkalis or acids, any continued exposure to the eye, mouth, and skin should be ceased and the area flushed with water. Airway, breathing, circulation, and the overall cardiorespiratory status should be addressed following any possible ingestion. Endotracheal intubation or tracheostomy may be required if severe upper airway edema is present.
Although large quantities of fluid (eg, water, milk) have often been given to dilute the corrosive agent, be aware that if perforation has occurred, these fluids may extravasate, leading to mediastinitis. Large volumes of fluid may also induce vomiting, but a small amount of water or milk may wash away any residual agent from the mucosal surface.
If alkaline or acidic fluids are given, an exothermic reaction can occur. Induced emesis or gastric lavage for GI decontamination is contraindicated and may exacerbate esophageal injury or lead to aspiration. Charcoal is not recommended.
Most children who have ingested a caustic substance need to be admitted at least for observation to keep them on nothing by mouth (NPO) status, provide intravenous hydration until endoscopy, and monitor vital signs and respiratory distress.
If no mucosal burns are detected, a patient may be discharged home after tolerating a normal diet. For patients with first-degree burns only, observe for at least 48-96 hours and until tolerating a normal diet. Patients with second- and third-degree burns require prolonged hospitalization.
Broad-spectrum antibiotics may be used in severe cases to prevent secondary infection. The use of systemic corticosteroids is controversial, but they may be used in an attempt to decrease stricture formation. Surgical management of perforations and revisions may be required.
Treatment of Infectious Esophagitis
Infectious esophagitis requires the appropriate antiviral, antifungal, or antibiotic therapy based on the causative organism. For bacterial esophagitis, drainage of a paraesophageal abscess may be required.
Treatment of Eosinophilic Esophagitis
The treatment of eosinophilic esophagitis is still widely debated. [4] Patch testing in combination with skin prick testing can help determine the causative food allergen (most commonly, milk, eggs, wheat, beef, soy, chicken). [35]
Selective elimination of implicated foods based on allergy testing or, in certain cases, initiation of elemental diet is required. For 1-3 months, patients are placed on an exclusion diet or an elemental diet, and repeat endoscopies with biopsies are often necessary to determine both improvement and the time to start progressive reintroduction of foods. Elemental diet has a higher success rate than testing-based elimination diet. [36, 37]
Other treatments, such as anti-inflammatory medications, mast cell stabilizers, and leukotriene receptor antagonists, have also been used. Oral corticosteroids were demonstrated to be effective in treating symptoms and normalizing the histology, but the disease recurs when these agents are discontinued.
Since 1998, multiple studies have demonstrated the effectiveness of swallowed topical corticosteroids delivered from a metered dose inhaler (fluticasone) or oral viscous budesonide in treating clinical symptoms and abnormal histology associated with eosinophilic esophagitis. [38, 39, 40] When using swallowed fluticasone, patients should be instructed to administer the metered dose inhaler without using a spacer. The inhaler should be inserted into the mouth and sprayed with the lips sealed around the device; the powder should then be swallowed and not rinsed. The patient should not eat or drink for at least 30 minutes. When using oral viscous budesonide, the patient should not eat or drink for at least 30 minutes after taking the medication.
The course of treatment with topical corticosteroids should be 4-12 weeks. However, similar to the effect seen with oral steroid treatment, the disease generally recurs upon discontinuation of treatment. [41]
The use of a topical steroid for maintenance treatment has not been widely studied. The adverse effects with this form of treatment are thought to be significantly less than those with oral steroid therapy because of the much smaller dose and the rapid metabolism by the liver with first-pass effect. In adults, initial studies are not promising that response to swallowed topical steroids is long lasting. [42]
Oral cromolyn sodium and other mast cell stabilizers have not been shown to be effective. Studies have demonstrated benefits from leukotriene-receptor antagonists in adults, and studies of monoclonal antibodies directed against interleukin (IL)–5 are ongoing. [43, 44]
Dietary Measures
No dietary changes are required once proper medical treatment is successfully initiated. However, foods that exacerbate reflux or delay gastric emptying (eg, fats, fried foods, tomatoes, caffeine) should be restricted.
Prevention of Esophagitis
Prevention of accidental ingestion is critical, because of the potentially high associated morbidity and mortality. Corrosive agents should be locked up and kept out of reach of young children and maintained in their closed original containers.
Consultations
Consult a gastroenterologist, especially if endoscopy or biopsy is required for definitive diagnosis. [45]
For corrosive ingestions, always notify a local Poison Control Center. Their staff can help identify problematic active ingredients and provide immediate management and monitoring guidelines. A gastroenterologist and, possibly, a surgeon need to be consulted. A significant number of patients have esophageal burns without oral burns.
Long-Term Monitoring
Close monitoring with the primary physician after caustic ingestion is important in the early detection and intervention of stricture formation. Among patients who develop strictures, 50% develop them in 1 month, 80% develop them in 2 months, and all patients develop them by 8 months. Late esophageal squamous carcinoma is rare.
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Location of fungal and viral infections in ulcers.
