Oesophagitis

Inflammation of the oesophageal mucosa from reflux, infection, drugs, allergy, caustic injury, radiation or systemic disease, producing odynophagia, dysphagia, heartburn and chest pain.

• Causes and typical frequency:
  • Reflux (about 60 to 70% of cases in the general population).
  • Infection: Candida (commonest in immunocompromised patients), herpes simplex virus, cytomegalovirus, and rarely mycobacteria, bacteria and Histoplasma.
  • Pill injury: doxycycline, NSAIDs, bisphosphonates, potassium chloride, ferrous sulfate.
  • Eosinophilic oesophagitis (allergic, about 1 in 1000 to 2000 people, mostly young men with atopy).
  • Caustic ingestion, radiation, graft-versus-host disease, Crohn disease, lichen planus, Behcet disease.
• Mechanism: damage to the epithelial barrier by acid, pathogens, direct toxicity, or eosinophilic and lymphocytic inflammation, with ulceration, oedema and fibrosis; chronic disease causes stricture.

Odynophagia (pain on swallowing; suggests infection, pill injury or ulcer), dysphagia (suggests eosinophilic disease, stricture or severe inflammation), heartburn, retrosternal chest pain, regurgitation, food bolus impaction (eosinophilic), haematemesis or melaena (severe).

• Oral thrush, oral herpetic lesions, HIV risk, immunosuppressive therapy, atopy (asthma, eczema, food allergy), recent pill ingestion (mid-oesophageal pain after lying down with tablets).
• Examination: oral candidiasis or herpetic lesions, signs of immunosuppression, atopic disease.
• Differential diagnosis: coronary disease (always exclude in chest pain), pericarditis, achalasia, oesophageal spasm, oesophageal cancer, peptic ulcer, functional heartburn, aortic dissection, mediastinitis.
• Complications: stricture, bleeding, perforation, food impaction, weight loss and dehydration, Barrett oesophagus (reflux), fistula, and malnutrition.

Exclude cardiac causes first (ECG and troponin) when chest pain is present.

• Upper endoscopy with biopsies (the key test), choosing the biopsy site by the endoscopic pattern: reflux (erosions at the lower end), Candida (white plaques; brush cytology, biopsy), herpes (shallow punched-out ulcers; edge biopsies), cytomegalovirus (large linear ulcers; ulcer base biopsies), pill injury (discrete ulcer in the mid oesophagus), eosinophilic (rings, furrows, white exudates, narrowing; at least six biopsies from two levels, with 15 or more eosinophils per high-power field diagnostic).
• HIV test and CD4 count, full blood count, glucose and HbA1c, hepatitis serology; allergy testing in eosinophilic disease.
• Barium swallow or CT for stricture, perforation or fistula; chest X-ray for mediastinal air.
• pH-impedance monitoring or manometry for refractory reflux symptoms.

Initial care: stop the cause (pills, alcohol, smoking), upright posture, soft or liquid diet, adequate oral fluids; analgesia with paracetamol 1 g four times daily and viscous lidocaine 2% 15 mL swish and swallow before meals (maximum 8 doses a day); IV fluids for dehydration.

• Reflux oesophagitis: omeprazole 20 to 40 mg daily for 8 weeks (40 mg daily for severe erosions), then the lowest effective dose; alginate-antacid after meals; weight loss; head of bed raised.
• Candida: fluconazole 400 mg loading then 200 to 400 mg daily for 14 to 21 days (IV 400 mg daily if unable to swallow); echinocandin (caspofungin 70 mg then 50 mg IV daily, or micafungin 150 mg IV daily) or voriconazole 200 mg twice daily for fluconazole-resistant disease.
• Herpes simplex: aciclovir 400 mg orally five times daily (or valaciclovir 1 g three times daily) for 7 to 14 days (14 to 21 days in immunocompromised patients); IV aciclovir 5 mg/kg every 8 hours when unable to swallow.
• Cytomegalovirus: ganciclovir 5 mg/kg IV every 12 hours for 3 to 6 weeks, then valganciclovir 900 mg twice daily when oral intake is possible, with renal dose adjustment; antiretroviral therapy in HIV.
• Pill oesophagitis: stop the drug or change formulation, swallow tablets with 200 to 250 mL of water in an upright position and stay upright for 30 to 60 minutes; omeprazole 20 to 40 mg daily for 2 to 4 weeks.
• Eosinophilic oesophagitis: omeprazole 20 to 40 mg twice daily for 8 weeks; swallowed topical corticosteroid (fluticasone propionate 880 micrograms twice daily from a metered inhaler, swallowed without a spacer, or budesonide orodispersible tablet 1 mg twice daily) for 8 to 12 weeks, then maintenance at the lowest effective dose; no food or drink for 30 minutes after; dupilumab 300 mg SC weekly for refractory disease in adults and adolescents of 40 kg or more; dietary elimination (milk, wheat, egg, soy, nuts, fish); dilatation for strictures.
• Caustic ingestion: nil by mouth, airway and fluid resuscitation, endoscopy within 12 to 24 hours, no induced vomiting or neutralisation, omeprazole 40 mg IV twice daily, surgery for perforation or necrosis; dilatation for strictures after 3 to 6 weeks.
• Radiation, graft-versus-host disease, Crohn disease and Behcet disease: specialist treatment (for example prednisolone 0.5 to 1 mg/kg daily, with topical steroid for graft-versus-host disease), plus omeprazole 40 mg daily.
• Stricture: balloon or bougie dilatation, starting at 7 to 10 mm and progressing by 1 to 2 mm per session to 15 to 18 mm, with omeprazole 40 mg daily.
• Special groups: children (omeprazole 1 mg/kg daily for reflux and eosinophilic disease, fluconazole 6 mg/kg loading then 3 to 6 mg/kg daily, maximum 400 mg, for Candida; aciclovir 10 mg/kg every 8 hours IV for herpes); pregnancy (alginates, famotidine 20 mg twice daily, omeprazole 20 mg daily; avoid high-dose fluconazole in the first trimester and use liposomal amphotericin B 3 mg/kg/day if needed); elderly (review pills, check for dysphagia and aspiration); renal impairment (reduce aciclovir, ganciclovir, valganciclovir and famotidine doses); immunosuppression (antiretroviral therapy, prompt treatment, secondary prophylaxis where required).
• Red flags: haematemesis, inability to swallow saliva, fever with chest pain, subcutaneous emphysema or mediastinal air, food impaction, weight loss, dysphagia lasting more than 2 weeks, immunosuppression.
• Follow-up: review at 2 to 8 weeks depending on cause; repeat endoscopy at 8 weeks for severe erosive reflux, non-healing ulcers, or eosinophilic disease to assess response; surveillance for Barrett oesophagus when found.