GASTROINTESTINAL

2. ESOPHAGITIS
I. PATHOPHYSIOLOGY IV. COMPLICATIONS OF ESOPHAGITIS V. DIAGNOSTIC APPROACH TO ESOPHAGITIS
II. CAUSES OF ESOPHAGEAL INJURY: A. UPPER GI BLEED A. ASSESS FOR EVIDENCE OF ESOPHAGEAL PERFORATION
III. CLASSIC FINDINGS OF ESOPHAGITIS B. ESOPHAGEAL STRICTURES B. ASSESS FOR EVIDENCE OF ESOPHAGITIS AND POSSIBLE ETIOLOGY
A. DYSPHAGIA C. ESOPHAGEAL PERFORATION VI. TREATMENT OF ESOPHAGITIS
B. ODYNOPHAGIA A. PREVENTION OF FURTHER ESOPHAGEAL EROSION
B. TREATMENT OF UNDERLYING CAUSE

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I. Pathophysiology
o Injury to the esophageal mucosa → Inflammation of the esophageal lining → Esophagitis

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II. Causes of Esophageal injury
1. Pill-Induced
NSAIDs, Doxycycline, Potassium chloride, and Bisphosphonates
→ Results in direct mucosal injury

2. Reflux
Chronic GERD → Reflux of HCL → Erosion and inflammation of
the esophageal lining

3. Infectious
CMV, HSV, Candida → Infection and inflammation of the
esophageal lining
o Associated with Immunocompromised states (e.g. HIV/AIDs)

4. Caustic
Laundry detergents → Results in direct mucosal injury
o Associated with suicide attempts

5. Eosinophilic
Food allergens → Eosinophilic infiltration into esophagus →
Inflammation of the esophageal lining
o Associated with atopy (dermatitis, rhinitis, eczema)

III. Classic Findings of Esophagitis

A. Dysphagia
Difficulty swallowing
o Associated with Pill-Induced, Reflux and Eosinophilic
Esophagitis

B. Odynophagia
Pain with swallowing
o Associated with Infectious and Caustic Esophagitis

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IV. Complications of Esophagitis
A. Upper GI bleed B. Esophageal Strictures C. Esophageal perforation
Pathophysiology: Pathophysiology: Pathophysiology:
o Inflammation and erosions of the o Repeated inflammation of the o Erosions and ulceration of the esophageal
esophageal mucosa→ Erosions into esophageal mucosa→ Fibrosis of the lining extending transmurally→ Air and
esophageal arteries→ Blood enters esophageal lumen in attempts to esophageal contents can escape into the
the esophageal lumen repair→ Narrowing of the esophageal mediastinum
Presentation: lumen→ Difficulty moving foods and Presentation:
o Melena fluids through the esophagus o Subcutaneous Emphysema:
o Hematemesis Presentation:  Occurs due to air moving up the
o Anemia o Dysphagia and vomiting mediastinum into the subcutaneous
o Weight loss tissue in the neck and chest→ Results in
precordial crepitations on palpation→
Hamman’s sign
o Pneumomediastinum:
 Weight loss
o High Risk of Mediastinitis and Sepsis

Esophagitis Esophagitis Esophagitis

GI Bleed Strictures Esophageal

Perforation

Subcutaneous
Dysphagia Emphysema
Hematemesis Melena +
Vomiting +
Pneumomediastinum

Sepsis Chest pain

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V. Diagnostic Approach to Esophagitis

A. Assess for Evidence of Esophageal Perforation

1. Obtain a CXR 2. Obtain Contrast Esophagram
Indications: Indications:
o Assess for Esophageal perforation in patients with dysphagia o Concern for esophageal perforation with presence of
and new onset chest pain, fevers, leukocytosis, and Hamman’s pneumomediastinum
sign Abnormal Findings:
Abnormal Findings: o The “leaking of contrast into the mediastinum” →
o The presence of a Pneumomediastinum→ Possibility of an Esophageal Perforation
Esophageal Perforation

FIGURE 1. BLACK ARROW: SUBCUTANEOUS EMPHYSEMA FIGURE 2. ESOPHAGEAL PERFORATION ON CONTRAST ESOPHAGRAM
WHITE ARROW: PNEUMOMEDIASTINUM

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 B. Assess for Evidence of Esophagitis and Possible Etiology
1. Obtain Esophagogastroduodenoscopy (EGD)
Indications:
o Findings of Esophagitis Complications:
 Strictures
• Vomiting
• Weight loss
 GI Bleed
• Anemia
• Melena

Abnormal Findings:

a) EGD Visualization: b) Biopsy Samples:

o Pill fragments may reveal Pill-Induced Esophagitis o Hyphae on biopsy → Candida Esophagitis
o Erosions with strictures may suggest Reflux Esophagitis  Assess for Thrush
o Esophageal rings may suggest Eosinophilic Esophagitis o Giant cells with Cowdry A inclusion bodies → HSV Esophagitis
o Eschars may suggest Caustic Esophagitis  Assess for Oral Ulcers
 EGD should be avoided in Caustic Esophagitis given the o Cytomegaly with inclusion bodies → CMV Esophagitis
concern for perforation  Assess for CMV Retinitis
o Intraepithelial eosinophils → Eosinophilic Esophagitis

FIGURE 3. CMV ESOPHAGITIS FIGURE 4. CANDIDA ESOPHAGITIS FIGURE 7. HYPHAE ON BIOPSY FIGURE 8. GIANT CELLS WITH
INCLUSION BODIES ON BIOPSY

FIGURE 5. HSV ESOPHAGITIS FIGURE 6. EOSINOPHILIC ESOPHAGITIS FIGURE 9. CYTOMEGALY WITH FIGURE 10. INTRAEPITHELIAL
INCLUSION BODIES ON BIOPSY EOSINOPHILS CELLS ON BIOPSY

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VI. Treatment of Esophagitis
A. Prevention of esophageal erosion B. Treatment of Underlying Cause
1. Proton Pump Inhibitors (e.g. Omeprazole, Pantoprazole) 1. Pill-Induced Esophagitis
Indications: Treatment:
o Esophagitis of any etiology o Consume pills with a full glass of water and remain upright for
Purpose: ~30 mins
o ↓HCL production in stomach → ↓HCL refluxed into distal Monitoring:
esophagus → ↓Esophagitis severity and complications o Improvement/resolution of dysphagia
Monitoring:
o Improvement/resolution of dysphagia or odynophagia 2. Infectious Esophagitis
Treatments:
o Oral Fluconazole for Candida Esophagitis

PPI
o Acyclovir for HSV Esophagitis
o Ganciclovir for CMV Esophagitis
Monitoring:
o Improvement/resolution of dysphagia and odynophagia

- 3. Eosinophilic Esophagitis
Treatment: Fluticasone
o Avoid food allergens
o Fluticasone propionate sprayed -

orally and swallowed

Monitoring:
o Improvement/resolution of dysphagia
Eosinophilic
Infiltration
4. Caustic Esophagitis

PPI
Treatments:
o Avoid emesis or neutralization of caustic substance
Monitoring:
o Improvement/resolution of dysphagia and odynophagia
o Monitor for signs and symptoms of Esophageal Perforation

HCl secretion

Esophagitis

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