ESOPHAGEAL INFLAMMATION

VIRAL ESOPHAGITIS

Herpesviruses I and II, varicella-zoster virus, and CMV can all cause esophagitis; particularly common in immunocompromised pts (e.g., AIDS). Odynophagia, dysphagia, fever, and bleeding are symptoms and signs. Diagnosis is made by endoscopy with biopsy, brush cytology, and culture.

Treatment: Viral Esophagitis

Disease is usually self-limited in the immunocompetent person; viscous lidocaine can relieve pain; in immunocompetent pts, herpes and varicella esophagitis are treated with acyclovir, 200 mg PO five times a day for 7−10 days; in prolonged cases and in immunocompromised hosts, treatment is with acyclovir, 400 mg PO five times a day for 14–21 days, famciclovir, 500 mg PO tid, or valacyclovir 1 g PO tid for 7 days. CMV is treated with ganciclovir, 5 mg/kg IV q12h, until healing occurs, which may take weeks. Oral valganciclovir (900 mg bid) is an effective alternative to parenteral treatment. In nonresponders, foscarnet, 90 mg/kg IV q12h for 21 days, may be effective.

CANDIDA ESOPHAGITIS

In immunocompromised hosts, or those with malignancy, diabetes, hypoparathyroidism, hemoglobinopathy, systemic lupus erythematosus, corrosive esophageal injury, candidal esophageal infection may present with odynophagia, dysphagia, and oral thrush (50%). Diagnosis is made on endoscopy by identifying yellow-white plaques or nodules on friable red mucosa. Characteristic hyphae are seen on KOH stain. In pts with AIDS, the development of symptoms may prompt an empirical therapeutic trial.

Treatment: Candida Esophagitis

In immunocompromised hosts, fluconazole, 200 mg PO on day 1 followed by 100 mg daily for 2–3 weeks, is treatment of choice; alternatives include itraconazole, 200 mg PO bid, or ketoconazole, 200–400 mg PO daily; long-term maintenance therapy is often required. Poorly responsive pts or those who cannot swallow may respond to caspofungin 50 mg IV qd for 7–21 days.

PILL-RELATED ESOPHAGITIS

Doxycycline, tetracycline, aspirin, nonsteroidal anti-inflammatory drugs, KCl, quinidine, ferrous sulfate, clindamycin, alprenolol, and alendronate can induce local inflammation in the esophagus. Predisposing factors include recumbency after swallowing pills with small sips of water and anatomic factors impinging on the esophagus and slowing transit.

Treatment: Pill-Related Esophagitis

Withdraw offending drug, use antacids, and dilate any resulting stricture.

EOSINOPHILIC ESOPHAGITIS

Mucosal inflammation with eosinophils with submucosal fibrosis can be seen especially in pts with food allergies. This diagnosis relies on the presence of symptoms of esophagitis with the appropriate findings on esophageal biopsy. Eotaxin 3, an eosinophil chemokine, has been implicated in its etiology. IL-5 and TARC (thymus and activation-related chemokine) levels may be elevated. Treatment involves a 12-week course of swallowed fluticasone (440 µg bid) using a metered-dose inhaler. In 30−50% of pts, proton pump inhibitors can reduce eosinophil infiltrates.

OTHER CAUSES OF ESOPHAGITIS IN AIDS

Mycobacteria, Cryptosporidium, Pneumocystis, idiopathic esophageal ulcers, and giant ulcers (possible cytopathic effect of HIV) can occur. Ulcers may respond to systemic glucocorticoids.

Outline

ESOPHAGEAL INFLAMMATIONis the Harrison's Manual of Medicine Word of the day!