History

Fact Explanation
Asymptomatic Some patients with esophagitis can be asymptomatic. [5]
Dyspepsia Dyspepsia (heart burn) is the most common presentation of the esophagitis. Reflux of acidic gastric contents in to the esophagus causes dyspepsia. [2]
Chest pain [2,3] Retrosternal or epigastric burning pain is characteristic of reflux esophagitis. [6]
Water brash Water brash is the increased production of saliva. It is seen in reflux esophagitis. [7]
Regurgitation Regurgitation of acidic gastric contents occurs in reflux esophagitis. Some patients complain of reflux of bitter taste. Regurgitation is frequent when the patient is in supine position, bending forwards or wearing tight clothes after a heave meal. [4]
Upper abdominal discomfort [2,3] This is due to irritation of the esophagus due to acid reflux. Some complain of abdominal bloating sensation. [8]
Nausea and or vomiting [2] Patients with esophagitis can have anorexia, nausea and vomiting.
Dysphagia Patients complain of dysphagia which occurs secondary to fibrosis and stricture formation. Some patients complain of odynophagia and sensation of food getting stuck in the mid-esophagus as well. These complaints are common in infective esophagitis (candida, cytomegalovirus, herpes simplex virus and HIV), eosinophilic esophagitis. [1]
Symptoms of lower respiratory tract infection Patients can have aspiration pneumonia secondary to aspiration of gastric contents in to the bronchi. Cough, wheezing, pleuritic chest pain and fever are symptoms of lower respiratory tract infection. [4]
Cough Cough can be secondary to laryngeal inflammation. [4]
Hoarseness of voice Irritation of vocal cords can cause hoarseness of voice. [4]
Fever Patients with infective esophagitis can have fever. Classic triad of odynophagia, retrosternal pain and fever is seen in patients with herpes simplex virus esophagitis. [9]
Hematemesis Hematemesis is seen in patients with Herpes simplex virus esophagitis. [9]
Risk factors Obese patients are at risk of reflux esophagitis. Immunecompromised patients either acquired or congenital, are at risk of developing herpes esophagitis and candida esophagitis. [9]
Drug history Certain drugs like alendronate, doxycycline and other antibiotics can cause drug induced esophagitis. [10,11]
References
  1. WHITNEY-MILLER C. L., KATZKA D., FURTH E. E.. Eosinophilic Esophagitis: A Retrospective Review of Esophageal Biopsy Specimens From 1992 to 2004 at an Adult Academic Medical Center. American Journal of Clinical Pathology [online] December, 131(6):788-792 [viewed 20 July 2014] Available from: doi:10.1309/AJCPOMPXJFP7EB4P
  2. NONEVSKI I. T., DOWNS-KELLY E., FALK G. W.. Eosinophilic esophagitis: An increasingly recognized cause of dysphagia, food impaction, and refractory heartburn. Cleveland Clinic Journal of Medicine [online] 2008 September, 75(9):623-633 [viewed 20 July 2014] Available from: doi:10.3949/ccjm.75.9.623
  3. VERNON NATALIA, MOHANANEY DIVYANSHU, GHETMIRI EHSAN, GHAFFARI GISOO. Esophageal Rupture as a Primary Manifestation in Eosinophilic Esophagitis. Case Reports in Medicine [online] 2014 December, 2014:1-5 [viewed 20 July 2014] Available from: doi:10.1155/2014/673189
  4. KATZ PHILIP O, GERSON LAUREN B, VELA MARCELO F. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol [online] December, 108(3):308-328 [viewed 20 July 2014] Available from: doi:10.1038/ajg.2012.444
  5. NAGAHARA A, HOJO M, ASAOKA D, SASAKI H, OGURO M, MORI H, MATSUMOTO K, OSADA T, YOSHIZAWA T, WATANABE S. Clinical feature of asymptomatic reflux esophagitis in patients who underwent upper gastrointestinal endoscopy. J Gastroenterol Hepatol [online] 2012 Apr:53-7 [viewed 20 July 2014] Available from: doi:10.1111/j.1440-1746.2012.07073.x
  6. ROBERTS R. Esophageal disease as a cause of severe retrosternal chest pain.. CHEST [online] 1975 May [viewed 20 July 2014] Available from: doi:10.1378/chest.67.5.523
  7. CHAIT MM. Gastroesophageal reflux disease: Important considerations for the older patients World J Gastrointest Endosc [online] 2010 Dec 16, 2(12):388-396 [viewed 20 July 2014] Available from: doi:10.4253/wjge.v2.i12.388
  8. GAUDE GS. Pulmonary manifestations of gastroesophageal reflux disease Ann Thorac Med [online] 2009, 4(3):115-123 [viewed 20 July 2014] Available from: doi:10.4103/1817-1737.53347
  9. AL-HUSSAINI AA, FAGIH MA. Herpes Simplex Ulcerative Esophagitis in Healthy Children Saudi J Gastroenterol [online] 2011, 17(5):353-356 [viewed 20 July 2014] Available from: doi:10.4103/1319-3767.84496
  10. LIBERMAN URI A., HIRSCH LAURENCE J.. Esophagitis and Alendronate. N Engl J Med [online] 1996 October, 335(14):1069-1070 [viewed 21 July 2014] Available from: doi:10.1056/NEJM199610033351416
  11. KIKENDALL JW. Pill-Induced Esophagitis Gastroenterol Hepatol (N Y) [online] 2007 Apr, 3(4):275-276 [viewed 21 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099275

Examination

Fact Explanation
BMI Most of the patients with GERD are obese. [2]
Examination of the oral cavity In patients with oropharyngeal candidiasis, oral thrush will be seen as curd like white plaques. [3]
Varicella zoster skin lesions Patients with varicella zoster have simultaneous dermatological involvement. Vesicular lesions are seen in the oral mucosa as well. [1]
Signs of lower respiratory tract infection Patients with GERD can have respiratory tract infections secondary to aspiration of gastric contents in to the bronchi. Patients are febrile, and have evidence of pulmonary consolidation. Commonly over the base of the right lung. [4]
References
  1. AL-HUSSAINI AA, FAGIH MA. Herpes Simplex Ulcerative Esophagitis in Healthy Children Saudi J Gastroenterol [online] 2011, 17(5):353-356 [viewed 20 July 2014] Available from: doi:10.4103/1319-3767.84496
  2. MURRAY L.. Relationship between body mass and gastro-oesophageal reflux symptoms: The Bristol Helicobacter Project. International Journal of Epidemiology [online] 2003 August, 32(4):645-650 [viewed 20 July 2014] Available from: doi:10.1093/ije/dyg108
  3. SAMONIS GEORGE, SKORDILIS PANAGIOTIS, MARAKI SOFIA, DATSERIS GEORGE, TOLOUDIS PARASCHOS, CHATZINIKOLAOU IOANNIS, GEORGOULIAS VASSILIOS, BODEY GERALD P.. Oropharyngeal Candidiasis as a Marker for Esophageal Candidiasis in Patients with Cancer. CLIN INFECT DIS [online] 1998 August, 27(2):283-286 [viewed 20 July 2014] Available from: doi:10.1086/514653
  4. KHAN AN, AL-JAHDALI H, AL-GHANEM S, GOUDA A. Reading chest radiographs in the critically ill (Part II): Radiography of lung pathologies common in the ICU patient Ann Thorac Med [online] 2009, 4(3):149-157 [viewed 20 July 2014] Available from: doi:10.4103/1817-1737.53349

Differential Diagnoses

Fact Explanation
Acute coronary syndrome Patients with acute coronary syndrome also presents with chest pain. It is always safe to exclude the possibility of acute coronary syndrome in patients presenting with chest pain. [2]
Pericardial effusion This also presents with pleuritic type of chest pain which is relieved by bending forwards. On auscultation of the precordium a pericardial friction rub is heard over the left lower sternal border. [6]
Aortic Dissection Patients with acute dissection presents with severe tearing type of chest pain which radiates to the back. [7]
Esophageal stricture Benign and malignant esophageal strictures can cause dysphagia. [8]
Hypereosinophilic syndrome This is another cause for the presence of increased number of eosinophils in the esophagus. Full blood count shows increased number of eosinophils in the peripheral blood as well. [1]
Achalasia Patients with achalasia also presents with dysphagia. Esophageal manometry is indicated to diagnose achalasia, which demonstrates aperistalsis and increased resting lower esophageal sphincter pressure. [3]
Hiatus hernia Hiatus hernia can cause reflux and esophagitis. Patients presents with chest pain and regurgitation. Upper gastrointestinal endoscopy can aid in the diagnosis. [4]
Crohn's disease Gastrointestinal inflammation is seen in Crohn’s disease as well. [5]
References
  1. WHITNEY-MILLER C. L., KATZKA D., FURTH E. E.. Eosinophilic Esophagitis: A Retrospective Review of Esophageal Biopsy Specimens From 1992 to 2004 at an Adult Academic Medical Center. American Journal of Clinical Pathology [online] December, 131(6):788-792 [viewed 20 July 2014] Available from: doi:10.1309/AJCPOMPXJFP7EB4P
  2. KATZ PHILIP O, GERSON LAUREN B, VELA MARCELO F. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol [online] December, 108(3):308-328 [viewed 20 July 2014] Available from: doi:10.1038/ajg.2012.444
  3. NIGHAT F. M., MILES M. W., MUTASIM N. A. Achalasia: unusual cause of chronic cough in children. Cough [online] 2008, 4:6 [viewed 20 July 2014] Available from: doi:10.1186/1745-9974-4-6
  4. ROBERTS R. Esophageal disease as a cause of severe retrosternal chest pain.. CHEST [online] 1975 May [viewed 20 July 2014] Available from: doi:10.1378/chest.67.5.523
  5. AL-HUSSAINI AA, FAGIH MA. Herpes Simplex Ulcerative Esophagitis in Healthy Children Saudi J Gastroenterol [online] 2011, 17(5):353-356 [viewed 20 July 2014] Available from: doi:10.4103/1319-3767.84496
  6. NIKLAUS H. MUELLER, DONALD H. GILDEN, MARIA A. NAGEL. Varicella Zoster Virus Infection: Clinical Features, Molecular Pathogenesis of Disease, and Latency. Neurol Clin. [online] Aug 2008; 26(3): 675-viii. [viewed 20 July 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2754837/
  7. ALAN C. BRAVERMAN. Acute Aortic Dissection. Circulation. [online] 2010; 122: 184-188. [viewed 20 July 2014]. Available from: doi: 10.1161/ CIRCULATIONAHA.110.958975.
  8. KIM JH, SHIN JH, SONG HY. Benign Strictures of the Esophagus and Gastric Outlet: Interventional Management Korean J Radiol [online] 2010, 11(5):497-506 [viewed 19 July 2014] Available from: doi:10.3348/kjr.2010.11.5.497

Investigations - for Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy (UGIE) UGEI helps in diagnosing the presence of esophagitis. Reflux esophagitis is characterized by the presence of erythema, edema, and linear ulcers over the distal esophagus. [1] Candida esophagitis can be diagnosed by the presence of curd like white plaques. In advanced disease luminal narrowing can be seen. Herpes esophagitis have vesicles which later progress to linear ulcers. These are commonly observed over the mid and distal esophagus. [4] Endoscopic features of eosinophilic esophagitis include the presence of mucosal rings, furrows and white specks with narrow lumen. [1] UGIE can also detect the presence of concurrent hiatal hernia.
Biopsy Herpes esophagitis is characterized by the presence of inflammation, multinucleated giant cells, ballooning degeneration of the cells, ground glass appearance of the nuclei and inclusion bodies. [4] Eosinophilic esophagitis is diagnosed by the presence of 15 or more intraepithelial eosinophils per high-power field (GERD patients can also have increased numbers of eosinophils in the esophagus). Presence of epithelial basal cell hyperplasia, and elongated lamina propria papillae are histological features of reflux esophagitis. [1,2,4]
Culture Obtained biopsy samples can be used to isolate the possible organism. Viral cultures and fungal cultures are indicated whenever needed. [4]
Polymerase chain reaction (PCR) PCR can identify the genome of the virus causing esophagitis. It has 92% to 100% sensitivity and 100% specificity. [5]
Direct immunofluorescence assays This is 69 to 88% sensitive in isolating the infectious organism in infectious esophagitis. [5]
24 hour esophageal PH monitoring This aids in diagnosing GERD induced esophagitis. [1,3]
References
  1. WHITNEY-MILLER C. L., KATZKA D., FURTH E. E.. Eosinophilic Esophagitis: A Retrospective Review of Esophageal Biopsy Specimens From 1992 to 2004 at an Adult Academic Medical Center. American Journal of Clinical Pathology [online] December, 131(6):788-792 [viewed 20 July 2014] Available from: doi:10.1309/AJCPOMPXJFP7EB4P
  2. VERNON NATALIA, MOHANANEY DIVYANSHU, GHETMIRI EHSAN, GHAFFARI GISOO. Esophageal Rupture as a Primary Manifestation in Eosinophilic Esophagitis. Case Reports in Medicine [online] 2014 December, 2014:1-5 [viewed 20 July 2014] Available from: doi:10.1155/2014/673189
  3. KATZ PHILIP O, GERSON LAUREN B, VELA MARCELO F. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol [online] December, 108(3):308-328 [viewed 20 July 2014] Available from: doi:10.1038/ajg.2012.444
  4. AL-HUSSAINI AA, FAGIH MA. Herpes Simplex Ulcerative Esophagitis in Healthy Children Saudi J Gastroenterol [online] 2011, 17(5):353-356 [viewed 20 July 2014] Available from: doi:10.4103/1319-3767.84496
  5. MARINHO ANDRéIA VIDICA, BONFIM VINíCIUS MENDES, DE ALENCAR LUCIANA RODRIGUES, PINTO SEBASTIãO ALVES, ARAúJO FILHO JOãO ALVES DE. Herpetic Esophagitis in Immunocompetent Medical Student. Case Reports in Infectious Diseases [online] 2014 December, 2014:1-4 [viewed 20 July 2014] Available from: doi:10.1155/2014/930459

Investigations - Screening/Staging

Fact Explanation
Upper gastrointestinal endoscopy Patients with long term GERD can have Barrett esophagus as a complication of chronic acid reflux. Endoscopic screening is indicated if Barrett esophagus is suspected. In patients with endoscopic evidence of dysplasia annual endoscopic surveillance is indicated. If the subsequent endoscopies shows no dysplasia for two consecutive years endoscopy is done in every 3 years. Patients with persistent low-grade dysplasia should undergo endoscopic surveillance once in every 6 months intervals for a year and if they shows no progression of the lesions annual surveillance is adequate. [1]
References
  1. KATZ PHILIP O, GERSON LAUREN B, VELA MARCELO F. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol [online] December, 108(3):308-328 [viewed 20 July 2014] Available from: doi:10.1038/ajg.2012.444

Management - General Measures

Fact Explanation
Health education Obese patients with GERD should reduce weight. Patients should not take heave meals, lie down or bend forwards within about 3 hours of meals. It is better to avoid fried or fatty foods, chocolate, peppermint, coffee, carbonated beverages, citrus fruit juices, spicy foods, coffee, smoking and alcohol. Head end of the bed should be elevated. [2,3]
Analgesics Patients who complain of pain need analgesics to relieve pain.
Antipyeritics Patients with fever benefit from antipyretics. [4]
Hydration and nutrition Patients who have dysphagia and odynophagia may need intravenous fluids and or nutrition. [4]
Management of dysphagia Patients with dysphagia benefit from endoscopic dilatation. Intralesional injection of corticosteroids is also a treatment option for dysphagia secondary to stricture formation. [1,3]
References
  1. NONEVSKI I. T., DOWNS-KELLY E., FALK G. W.. Eosinophilic esophagitis: An increasingly recognized cause of dysphagia, food impaction, and refractory heartburn. Cleveland Clinic Journal of Medicine [online] 2008 September, 75(9):623-633 [viewed 20 July 2014] Available from: doi:10.3949/ccjm.75.9.623
  2. ANDERSON LESLEY A., CANTWELL MARIE M., WATSON R.G. PETER, JOHNSTON BRIAN T., MURPHY SEAMUS J., FERGUSON HEATHER R., MCGUIGAN JIM, COMBER HARRY, REYNOLDS JOHN V., MURRAY LIAM J.. The Association Between Alcohol and Reflux Esophagitis, Barrett's Esophagus, and Esophageal Adenocarcinoma. Gastroenterology [online] 2009 March, 136(3):799-805 [viewed 20 July 2014] Available from: doi:10.1053/j.gastro.2008.12.005
  3. KATZ PHILIP O, GERSON LAUREN B, VELA MARCELO F. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol [online] December, 108(3):308-328 [viewed 20 July 2014] Available from: doi:10.1038/ajg.2012.444
  4. AL-HUSSAINI AA, FAGIH MA. Herpes Simplex Ulcerative Esophagitis in Healthy Children Saudi J Gastroenterol [online] 2011, 17(5):353-356 [viewed 20 July 2014] Available from: doi:10.4103/1319-3767.84496

Management - Specific Treatments

Fact Explanation
Proton pump inhibitors (PPIs) PPIs (omeprazole, pantoprazole, lansoprazole) are the first line medical management option in treating patients with esophagitis secondary to GERD. PPIs are usually prescribed for 4 to 8 weeks. Delayed release PPIs are better prescribed 30 to 60 minutes before meals. Often therapeutic trial of PPIs is recommended to establish the diagnosis of GERD. Rapid symptomatic relief of symptoms in response to PPIs favors the diagnosis of GERD. [1]
Histamine-2 receptor antagonist (H2RA) H2RAs (ranitidine, cimetidine) are also used to treat GERD. This is better for maintenance therapy for symptomatic patients who have already prescribed PPIs. [1]
Anti-reflux surgery Anti-reflux surgery is indicated in patients with GERD whose symptoms fail to respond to medical treatment. Laparoscopic or open Nissen and partial fundoplications techniques are used in the treatment. [1,4,5]
Treatment of fungal esophagitis Mild fungal infection can be treated with topical nystatin, clotrimazole, and oral amphotericin B. Fluconazole and itraconazole oral preparations can also be used. Intravenous preparations used for severe infection include, amphotericin B, fluconazole, and flucytosine. [3]
Treatment of Herpes simplex virus esophagitis Herpes simplex virus esophagitis is a self-limiting condition in immune-competent patients. Antiviral treatment may be needed in severe infection or in immunocompromised patients. Acyclovir is commonly used for the treatment. [2]
References
  1. KATZ PHILIP O, GERSON LAUREN B, VELA MARCELO F. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol [online] December, 108(3):308-328 [viewed 20 July 2014] Available from: doi:10.1038/ajg.2012.444
  2. AL-HUSSAINI AA, FAGIH MA. Herpes Simplex Ulcerative Esophagitis in Healthy Children Saudi J Gastroenterol [online] 2011, 17(5):353-356 [viewed 20 July 2014] Available from: doi:10.4103/1319-3767.84496
  3. PAPPAS PETER G., REX JOHN H., SOBEL JACK D., FILLER SCOTT G., DISMUKES WILLIAM E., WALSH THOMAS J., EDWARDS JOHN E.. Guidelines for Treatment of Candidiasis. CLIN INFECT DIS [online] 2004 January, 38(2):161-189 [viewed 20 July 2014] Available from: doi:10.1086/380796
  4. ENGSTRöM C., CAI W., IRVINE T., DEVITT P. G., THOMPSON S. K., GAME P. A., BESSELL J. R., JAMIESON G. G., WATSON D. I.. Twenty years of experience with laparoscopic antireflux surgery. Br J Surg [online] December, 99(10):1415-1421 [viewed 21 July 2014] Available from: doi:10.1002/bjs.8870
  5. FURNéE EJ, DRAAISMA WA, BROEDERS IA, GOOSZEN HG. Surgical Reintervention After Failed Antireflux Surgery: A Systematic Review of the Literature J Gastrointest Surg [online] 2009 Aug, 13(8):1539-1549 [viewed 21 July 2014] Available from: doi:10.1007/s11605-009-0873-z