Esophagitis

Picture of esophagitis, inflammation of the esophagus lining.

• The esophagus is a muscular tube leading from the back of the throat into the stomach.
• Esophagitis is an inflammation of the lining of the esophagus, caused by infection or irritation of the inner lining (mucosa) of the tube.
• Common symptoms include heartburn and painful swallowing.
• If undiagnosed or untreated, esophagitis can cause problems with swallowing, ulcers, scarring of the esophagus, or "Barrett's esophagus," which can be a precursor to esophageal cancer.
• Diet is often a key to limiting symptoms of esophagitis.
• Most individuals recover fully, although some have chronic inflammation that is managed with long-term medical treatment.

Esophagitis is caused by an infection or irritation of the esophagus. Bacteria, viruses, or fungi can cause infection. Individuals with weakened immune systems are more susceptible to these infections and may be at higher risk for esophagitis.

Infections that cause esophagitis include:

• Candida is a yeast infection of the esophagus. In people with weakened immune systems, such as those with diabetes, or HIV, those who have transplants or are undergoing chemotherapy, or people who have recently been on antibiotics, the yeast can overgrow in the esophagus, causing inflammation and pain. Candida is treatable with antifungal drugs.
• Herpes and Cytomegalovirus (CMV) are viral infections that can develop in the esophagus when the body's immune system is weak. It is treatable with antiviral drugs.

Irritation of the inner lining of the esophagus may be the cause of esophagitis. Reflux of stomach acid into the esophagus is a common cause of esophageal irritation. This may occur due to several conditions:

• GERD or gastroesophageal reflux disease: Weakness of the muscle between the stomach and esophagus (lower esophageal sphincter) can allow stomach acid to leak into the esophagus (acid reflux), irritating the inner lining. This is also referred to as GERD esophagitis, and in severe cases, it can become erosive esophagitis.
• Vomiting: Medical conditions that lead to frequent or chronic vomiting can also lead to acid damage to the esophagus. With excessive or forceful vomiting, small tears of the inner wall of the esophagus can occur, leading to further damage.
• Hernias: A part of the stomach can move above the diaphragm causing a hiatal hernia. This abnormality can lead to excess acid refluxing into the esophagus.
• Achalasia: This is a disorder where the lower end of the esophagus fails to open normally. As a result, food often gets stuck in the esophagus or is regurgitated.

Other causes of esophageal irritation can be a result of medical treatment:

• Surgery: Certain types of bariatric surgery can lead to an increased risk of esophagitis.
• Medications: Aspirin and other anti-inflammatory drugs can irritate the lining of the esophagus. They can also cause increased acid production in the stomach which leads to acid reflux. Large pills are taken without enough water, or taken just before bedtime can dissolve or get stuck in the esophagus, irritating.
• Radiation to the chest (thorax), for cancer treatment, can cause burns leading to scarring and inflammation of the esophagus.
• Swallowing foreign or toxic substances can irritate, damage, or burn the lining of the esophagus.
• Drinking alcohol and smoking can also increase the risk of developing esophagitis.

When left untreated, inflammation of the esophagus can cause changes in the cells that make up the inner lining (mucosa) of the esophagus. This condition is called Barrett's esophagus, which increases the risk for esophageal cancer.

Eosinophilic esophagitis is inflammation of the esophagus due to an over-proliferation of white blood cells (eosinophils) in the lining of the esophageal wall. This leads to dysmotility of the esophagus and difficulty swallowing. It is believed to be associated with different types of allergic reactions in people who are prone to hay fever, rhinitis, and dermatitis, and are more prone to eosinophilic esophagitis.

Symptoms of esophagitis include:

• Difficult and/or painful swallowing, especially if there is a feeling of food getting stuck on the way down
• Heartburn, acid reflux, or unpleasant taste in the mouth
• Sore throat or hoarseness
• Mouth sores
• Nausea, vomiting, or indigestion
• Chest pain, in the middle of the chest, often radiating to the back, is usually associated with swallowing or soon after a meal
• Bad breath (halitosis)
• Excessive belching

If you are experiencing chest pain that lasts more than a few minutes, especially if accompanied by shortness of breath or sweating, or if reflux symptoms are accompanied by fever, shortness of breath, excessive coughing, choking, or vomiting, call 911 immediately or activate the medical emergency response in your area and seek emergency care immediately.

If your symptoms are mild but have persisted for more than a few days, contact a health care practitioner.

Once the doctor has performed a thorough physical examination and reviewed the patient's medical history, medications may be prescribed to alleviate symptoms. If medications do not work, a doctor may refer the patient to a gastroenterologist, a physician who specializes in gastrointestinal disorders.

The gastroenterologist may recommend specialized tests to look for the cause and extent of the esophagitis. These tests include:

• Upper endoscopy: This is a test in which an endoscope is used to look directly into the esophagus and stomach. This is usually done as an outpatient procedure under mild sedation. During this procedure, samples of tissue may be taken (biopsy) to assess the severity of the damage to the esophagus.
• Upper GI series or barium swallow: This is a test where X-rays are taken of the esophagus after drinking a barium solution. Barium coats the lining of the esophagus and appears white on an X-ray. This test shows the location and extent of damage to the esophagus.

Treatment for esophagitis depends on its cause.

• If esophagitis is caused by an infection, it is treated with medications to eliminate the infection.
• If esophagitis is caused by acid reflux it is treated with medications that block acid production, for example, heartburn drugs. Depending on the cause of the reflux, different types of medications may be prescribed. In some cases, a surgical procedure may be recommended to treat the problem.
• If esophagitis is due to a medical procedure the patient may need to be maintained on acid blocking medications chronically. If the cause is due to taking medications, the patient may need to change those medications. Always consult a physician before stopping or changing medication.

Diet is often a key to limiting symptoms of esophagitis.

The GERD diet is aimed at reducing acid reflux, the main cause of esophagitis.

• Avoid fatty foods
• Avoid spicy foods
• Avoid acidic foods and beverages such as citrus and tomatoes
• Eat smaller meals
• Eat soft foods that are easily digested
• Avoid coffee (even decaffeinated), alcohol, soda, and chocolate

Other suggestions that may alleviate symptoms of GERD and esophagitis include:

• Stop smoking
• Remain upright while eating and for a time afterward
• Take small bites and chew food slowly
• Avoid eating within 3 hours of bedtime
• Lose weight
• Wear loose clothing

• If esophagitis is diagnosed early enough, medications and dietary or lifestyle changes are often enough to allow the body to heal.
• If the damage from esophagitis is severe or leads to scar tissue causing difficulty swallowing, more invasive treatment may be necessary.
• Endoscopy can be used to remove any lodged pill fragments, food, or foreign bodies stuck in the esophagus. Stretching (dilatation) of the esophagus can also be done as part of the endoscopy procedure.
• Surgery may be necessary to remove any damaged portions of the esophagus. In the case of Barrett's esophagus, where the risk of cancer is increased, surgery might be the treatment of choice.
• Eosinophilic esophagitis is treated with gentle stretching of the esophagus (dilatation) and medications to decrease white blood cells in the lining of the esophagus.
• Achalasia may be treated with stretching of the esophagus (dilatation) when oral medications fail to improve symptoms.

Treatment of esophagitis with medication depends upon the cause.

• Pain medications and medications that decrease inflammation such as corticosteroids can be used as adjuncts in the treatment of any inflammatory cause of esophagitis.
• Candida esophagitis is treated with antifungals (such as fluconazole [Diflucan] or nystatin [Bio-Statin, Mycostatin, Mycostatin Pastilles, Nilstat]), which can be administered IV or orally.
• Herpes and cytomegalovirus esophagitis is treated with antiviral medications (such as acyclovir [Zovirax] or valganciclovir [Valcyte]), which can be administered IV or orally.
• Acid reflux is treated with over-the-counter antacids (for example, calcium carbonate [Tums, Maalox, etc.] and Gaviscon).
  • A physician may prescribe or suggest medications that reduce acid production in the stomach. These medications include H2 blockers (ranitidine [Zantac], famotidine [Pepcid], cimetidine [Tagamet], and nizatidine [Axid]) or proton pump inhibitors (pantoprazole [Protonix], esomeprazole [Nexium], rabeprazole [Aciphex], lansoprazole [Prevacid], and omeprazole [Prilosec]).
• Barrett's esophagus is initially treated with proton pump inhibitors. If these do not help, patients are often given metoclopramide (Reglan) which can strengthen the lower esophageal sphincter, decreasing reflux. Some patients will require surgery.
• Eosinophilic esophagitis is treated with proton pump inhibitors and fluticasone propionate (Flovent), which is an inhaled steroid that reduces the proliferation of the white blood cells (eosinophils) and decreases inflammation.

• Achalasia is treated with nitrates (isosorbide dinitrate [Isordil]) and calcium channel blockers, (nifedipine [Procardia] and verapamil [Calan]). It may also be treated by injecting muscle-relaxing drugs such as botulinum toxin directly into the esophagus.

By following dietary and lifestyle recommendations such as those suggested for GERD, some types of esophagitis can be prevented.

Discuss symptoms with your physician early and start treatment promptly to prevent more severe inflammation.

In general, esophagitis caused by infection or inflammation is very treatable with mediation, dietary or behavioral modification, and in some cases, surgical intervention. Most individuals recover fully, although some have chronic inflammation that is managed with long-term medical treatment.

Few patients with GERD go on to develop Barrett's esophagus. Fewer than 1% of patients with Barrett's esophagus develop cancer. However, they are at an increased risk, and the esophagus should be monitored closely by a gastroenterologist.

The outlook for patients with eosinophilic esophagitis is favorable. It is a chronic, relapsing condition, but not usually one that is life-threatening. Treatments are evolving using different immune modulators to decrease allergy-like reactions.

Achalasia is a progressive, but treatable disorder. Close monitoring by a gastroenterologist is mandatory. A small number of individuals with achalasia may develop squamous cell cancer (carcinoma) as a result.