Esophagitis

Eosinophilic esophagitis

• •  Chronic, immune/antigen-mediated inflammation (eosinophil-predominant) 

  • ~15% percent of pts getting endoscopy for dysphagia have eosinophilic esophagitis

  • Associated with food allergies and atopy (asthma, eczema)

• SSX: Chronic dysphagia (solids), food impaction, chest/epigastric pain, heartburn

• DX: Endoscopy with biopsy (required for diagnosis) ↑ eosinophils (>15/HPF)

  • Shows stacked circular rings, white papules (eosinophil microabscesses), proximal strictures, linear furrows 

• TX: Allergist referral to identify food allergies and PPI's

  • Topical glucocorticoids (fluticasone - not inhaled but sprayed in mouth and swallowed or budesonide - in a viscous slurry PO)

  • Strictures can be dilated but must be done gradually over multiple dilations (↑ risk of tears/perforation)

Infectious

• • Usually in immunocompromised pts: chemo, post-transplant, HIV

  • SSX: Odynophagia, dysphagia (solids)

Candidiasis (MC)

• • • DX: Endoscopy shows mucosal plaques, biopsy shows yeasts and hyphae, culture reveals Candida

      • Can avoid scope if oral thrush is present (white plaques that can scrape off, leaving erythema ± bleeding)  

    • TX: PO fluconazole (systemic, never topical)

HSV

• DX: Endoscopy shows well circumscribed shallow ulcers (volcano-like); biopsy shows multinucleated giant cells, ground-glass nuclei, eosinophilic inclusions

  • Viral culture can confirm dx and identify resistant strains

• TX: Acyclovir PO, IV if can't tolerate PO (foscarnet if resistant)

CMV

• HIV pts with CD4 <50 and dysphagia and/or gastritis/enteritis/colitis 

• DX: Endoscopy shows linear/longitudinal ulcers, biopsy shows large cells with eosinophilic (intranuclear) and basophilic (intracytoplasmic) inclusions

  • Often have concurrent CMV retinitis (get ophtho to follow)

• TX: IV ganciclovir then PO when tolerated

Medication induced

• Bisphosphonates (risedronate) if not administered properly, tetracyclines, clindamycin, ASA/NSAIDs

  • Hx of taking med at bedtime without water

• SSX: Within hours-months of new medication ➔ chest pain/heartburn, odynophagia ➔ dysphagia, hematemesis 

• DX: Relief with d/c of medication within 1-2wks

  • Endoscopy for hematemesis or to r/o other causes shows normal mucosa surrounding a discrete ulcer

• TX: Stop medication, switch to liquid formulation, or educate to take with 8oz of water and stay seated/standing for 30 mins

• GERD: When physiologic reflux causes ssx

• Can be from hypotensive (relaxed) lower esophageal sphincter or transient relaxations of LES

  • or hiatal hernia ➔ gastroesophageal junction abnormality

• Classified as non-erosive reflux (ssx of GERD) or erosive esophagitis (endoscopic findings ± ssx of GERD)

• SSX: Classic - postprandial heartburn ± regurgitation

  • Chest pain, globus sensation, cough/hoarseness/wheezing, nausea, hypersalivation 

• DX: Classic ssx ➔ clinical dx

  • Ambulatory pH monitoring confirms; esophageal manometry to r/o motility disorder if c/o dysphagia

  • Upper endoscopy if alarm features:

    • Sudden dyspepsia in geriatric pt 

    • GI bleed/anemia

    • Unintended weight loss/cancer in 1° relative 

    • Dysphagia/odynophagia 

    • Barrett’s esophagus RF 

• TX: Lifestyle - elevate head of bed, don't eat 3 hours before bed, ↓ etOH/smoking/weight/irritating foods, 

  • Sx once or twice a week ➔ H2 blockers (famotidine) BID for at least 2 weeks

  • Sx more than twice a week or refractory to H2 blockers ➔ Proton Pump Inhibitors (omperazole)

    • Pts that fail to respond to QD PPIs have refractory GERD (can escalate to BID PPI)

  • Refractory to PPI ➔ antireflux surgery (fundoplication)

    • Gastric fundus secured around lower esophagus forming cuff ➔ narrowing at GE junction

    • And investigate for Zollinger Ellison