What is esophagitis?

Related conditions:
Gastroesophageal reflux disease (GERD), Barrett esophagus, heartburn (pyrosis), difficulty swallowing (dysphagia), painful swallowing (odynophagia)

Definition:
Esophagitis is a general condition in which the esophagus, the muscular tube connecting the mouth to the stomach, is inflamed. Different medical conditions are associated with esophagitis, including GERD, a condition in which the stomach contents flow backward into the esophagus, and nonreflux esophagitis. Serious gastrointestinal complications of esophagitis include a narrowing of the esophagus (strictures), ulcers, and in rare cases a risk of esophageal cancer.

Risk factors: Factors that may increase the risk of developing esophagitis include pregnancy, obesity, scleroderma, smoking, alcohol, caffeine, chocolate, fatty or spicy foods, spinal cord injury, and certain medications (such as nonsteroidal anti-inflammatory drugs, or NSAIDs, including aspirin and ibuprofen).

Etiology and the disease process: The etiology of esophagitis differs depending on the cause of the inflammation. In GERD-associated esophagitis, a backflow (reflux) of acidic fluid from the stomach (containing gastric acid, pepsin, and sometimes bile) to the esophagus causes irritation of the epithelium (the cells lining the esophagus). In some instances, a premalignant condition called Barrett esophagus can develop, which can increase the risk of developing esophageal cancer. However, the risk of esophageal cancer in patients with Barrett esophagus is relatively small: less than 1 percent of Barrett esophagus patients a year.

Nonreflux esophagitis may be caused by infection (viral, bacterial, fungal, or parasitic organisms), chemicals (ingestion of a caustic chemical or medication), radiation therapy (physically damaging the lining of the esophagus leading to inflammation and ulceration), or in rare instances immune-mediated disorders (eosinophilic esophagitis).

Incidence: Esophageal reflux symptoms are estimated to occur in up to 60 percent of the general population on a monthly basis with up to 20 percent of people having weekly symptoms. Radiation esophagitis occurs in up to 80 percent of patients receiving radiation therapy to the esophagus.

Symptoms: The most common symptom is heartburn (pyrosis). Other common symptoms of esophagitis include upper abdominal discomfort, nausea, bloating, and fullness. Less common symptoms of esophagitis include dysphagia, odynophagia, cough, hoarseness, wheezing, and vomiting of blood (hematemesis).

Screening and diagnosis: A physician can establish a diagnosis of GERD based on patient history alone. However, if symptoms are severe or do not respond to treatment, the physician may order diagnostic tests designed to determine mucosal injury, amount of reflux, and pathophysiology, including barium x-ray series, endoscopy, an ambulatory acid (pH) probe test, and an esophageal impedance test.

During a barium x-ray series, the patient drinks a barium solution that, through a series of x-rays, provides a picture of the shape and condition of the esophagus, stomach, and upper intestine (duodenum). X-rays can also reveal a hiatal hernia, an esophageal narrowing, or a growth.

During an endoscopy, or an esophagogastroduodenoscopy (EGD), a flexible tube with a light and camera (endoscope) is inserted down the throat and can reveal inflammation of the esophagus or stomach. A biopsy may also be taken during an EGD to test for Barrett esophagus, esophageal cancer, or the presence of a bacterium that may cause peptic ulcers.

An ambulatory acid (pH) probe test can identify when and for how long stomach acid flows back into the esophagus. A flexible tube (catheter) is inserted through the nose into the esophagus to position a probe in the esophagus just above the stomach. The other end of the catheter is attached to a small computer that records acid measurements. The probe remains in place for one or two days while measurements are recorded.

The esophageal impedance test is similar to the ambulatory acid probe test except that it measures whether gas or liquids reflux back into the esophagus.

Treatment and therapy: The goals of treatment are to provide symptom relief, heal ulcerations, and prevent complications. Reflux esophagitis is managed with over-the-counter agents, such as H2-receptor antagonists (cimetidine, ranitidine, famotidine, nizatidine) and with lifestyle changes such as altering eating habits (for example, avoiding alcohol, caffeine, carbonated beverages, chocolate, fatty foods, or overly large meals), ceasing to smoke cigarettes, and sleeping with the head of the bed elevated by about 4 to 6 inches. Proton pump inhibitors (omeprazole, lansoprazole, pantoprazole, esomeprazole, or rabeprazole) are frequently prescribed and appear highly effective at relieving symptoms and healing erosive esophagitis.

Infectious esophagitis is treated with antibiotics, whereas glucocorticoids are effective in patients with immune-mediated esophagitis. Radiation esophagitis treatment involves symptom management (similar to reflux esophagitis) and prevention (radioprotectors, varying treatment doses and schedules). For severe cases, a temporary feeding tube can be inserted into the stomach or surgery may be required to treat the injuries. To treat pain associated with esophagitis, a prescription analgesic can be gargled with and swallowed.

Prognosis, prevention, and outcomes: Though the response to therapy may be different depending on the specific cause of the esophagitis, the disorders that cause esophagitis usually respond to treatment.

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