Esophagitis

Esophagitis is an inflammation of the oesophagal mucosa.

Aetiology;

1. Gastroesophageal reflux disease( GERD) is the leading cause. The oesophagal mucosa is exposed to gastroduodenal contents for prolonged periods

Factors involved in the development of GERD include;

• Abnormalities of the lower oesophagal sphincter
• Hiatus hernia
• Delayed oesophagal clearance
• Increases gastric acid exposure time
• Defective gastric emptying
• Raised intra-abdominal pressure
• Patient factors- visceral sensitivity and patient vigilance
• Diet- fat, alcohol, tea, and coffee relax the lower oesophagal sphincter and may cause symptoms

2. Infections- candidiasis, herpes, CMV infection

3. Corrosives- ingestion of strong bleach and battery acid

4. Drugs- potassium supplements, NSAIDs, bisphosphonates and antibiotics such as tetracyclines

5. Eosinophilic esophagitis-

• more common in children
• It occurs more often in atopic individuals.
• Characterized by eosinophilic infiltration of the oesophagus

6. Immune-mediated disorders- Crohn’s disease, graft vs host disease

7. Others- achalasia, muscular dystrophy, radiotherapy

Clinical presentation

1. GERD- heartburn, and regurgitation are major

• Waterbrash- salivation due to reflex salivary gland stimulation
• The patient is often overweight
• Choking at night awakens the patient
• Odynophagia or dysphagia may be present
• Atypical chest pain
• Hoarseness of voice
• Recurrent chest infections, chronic cough, asthma

2. Esophageal candidiasis is more common in debilitated patients, HIV patients and those taking broad-spectrum antibiotics or cytotoxics

3. Corrosives- may present with painful burns to the mouth and pharynx

• Oesophageal perforation and mediastinitis may occur

4. Drugs- NSAIDs and potassium supplements may cause ulcers when tablets are trapped above a stricture

5. Eosinophilic esophagitis- dysphagia or foods bolus obstruction,

• Heartburn, chest pain and vomiting may be present

Investigations

-Recommended if patients present over the age of 55, symptoms are atypical or if a complication is suspected in the setting of GERD

-Endoscopy- investigation of choice

• A negative result in someone with compatible symptoms, still treat for GERD

-24-hour pH monitoring- when considering surgical intervention or the diagnosis is unclear. a pH of less than 4 for more than 6 to 7% of the study time is diagnostic of GERD

• Impedance testing is an alternative

-In eosinophilic esophagitis, endoscopy is usually normal, but mucosal rings, strictures or a narrowed oesophagus may be seen

Management

1. GERD-

-Lifestyle advice- weight loss, the elevation of bed head in those who have nocturnal symptoms, avoidance of foods that worsen symptoms, avoidance of late meals, smoking cessation

-PPIs – for those who fail lifestyle modification measures. Relieve symptoms and cure esophagitis

• Effective
• Recurrence is common when medication is stopped; some require lifelong treatment

-Domperidone- in those with dysmotility

-Antacids and alginates improve symptoms

-H2 receptor antagonist- for relief but not cure

*H pylori eradication has no value. However, it is advised for those who require PPIs for more than one year

-Laparoscopic antireflux surgery-

• Those who don’t respond to medical therapy, those unwilling to take long-term PPIs and those with severe regurgitation
• Complications of surgery- abdominal bloating, inability to vomit

Other causes;

-Treat infections

-Corrosives- analgesia, nutritional support

• Barium swallow demonstrates the extent of stricture; done after the acute phase.
• Endoscopic dilatation

-Drugs- use liquid preparations of NSAIDs and potassium supplements in patients with strictures. Cautious use of bisphosphonates in those with oesophagal disorders

-Eosinophilic esophagitis-

• Initially- Children- elimination diets; Adults- PPIs
• Topical glucocorticoids, e.g. fluticasone, for 8 to 12 weeks. Administered via a metered-dose inhaler. The patient sprays into the mouth and swallows
• Montelukast, if refractory symptoms occur

Complications

• Oesophageal perforation
• Mediastinitis
• Barrett’s oesophagus
• Adenocarcinoma
• Anaemia
• Oesophagal stricture
• Gastric volvulus