History

Fact Explanation
Dysphagia, Odynophagia, Retro-sternal pain Commonest presentation in patients with GERD. Heartburn or retrosternal pain is caused by acid reflux. These symptoms are also seen in patients with esophageal injuries induced by drugs or benign/malignant ulcerations. [9]
Hematemesis Erosion of esophageal lesions can present as hematemesis, such as in esophageal tuberculosis. [3]
Weight loss Odynophagia can cause a patient unwilling to eat leading to weight loss. [8]
Personal history Pre-existing oesophageal or swallowing disorders such as GERD and hiatal hernia, dysphagia, achalasia, esophageal strictures can lead to formation of esophageal ulcers. Irritants such as from cigarette smoking and alcohol can injure the esophageal lining and may be cause ulcers of the esophagus on chronic use. [8] Eating disorders such as Bulimia (forced vomiting) can also cause ulcers of the esophagus from the acidic effects of the repeated expulsion of acidic stomach contents.
Past history of GERD, infections of the upper GI tract, motility disorders A person with prolonged gastroesophageal reflux disease (GERD) is the most common cause leading to Barretts esophagus and ulceration of the esophagus. [7] Infections of the esophagus can also lead to ulceration and most common etiological agents are: herpes simplex, cytomegalovirus, human immunodeficiency virus ,tuberculosis and candida species. [1] Patients with esophageal motility disorders are at risk of pill-induced esophageal ulceration. [6]
Medications Frequent doses of multiple medications and prolonged contact of the drug with the esophageal mucosa due to a esophageal motility disorder or taking the pill with little water, can cause esophageal injury and may even lead to ulceration. [8] The commonest drugs known to induce esophageal injury leading to ulceration are NSAIDS, bisphosphonates, ferrous sulfate, nifedipine, quinidine, potassium chloride, and antibiotics such as doxycycline, tetracyclines, erythromycin, amoxicillin-clavulanate ,alendronate [4] and homeopathic medications. [8]
References
  1. SRILATHA PS, SUVARNA NIVEDITHA, GUPTA APARNA, BHAT GANESH. Esophageal ulcer in a HIV-seropositive patient co-infected by herpes simplex and cytomegalovirus. Indian J Pathol Microbiol [online] 2011 December [viewed 05 August 2014] Available from: doi:10.4103/0377-4929.77420
  2. SARAVANAN T, TELISINGHE PU, CHONG VH. Oesophageal ulcers secondary to doxycycline and herpes simplex infection in an immunocompetent patient. Singapore Med J [online] 2012 Apr, 53(4):e69-70 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22511065
  3. JAIN SS, SOMANI PO, MAHEY RC, SHAH DK, CONTRACTOR QQ, RATHI PM. Esophageal tuberculosis presenting with hematemesis World J Gastrointest Endosc [online] 2013 Nov 16, 5(11):581-583 [viewed 05 August 2014] Available from: doi:10.4253/wjge.v5.i11.581
  4. FERNANDOPULLE AN, NAVARATHNE NM. Oesophageal injury suspected to be due to doxycycline ingestion. Ceylon Med J [online] 2011 Dec, 56(4):162-3 [viewed 05 August 2014] Available from: doi:10.4038/cmj.v56i4.3897
  5. HAMADA YOHEI, NAGATA NAOYOSHI, HONDA HARUHITO, TERUYA KATSUJI, GATANAGA HIROYUKI, KIKUCHI YOSHIMI, OKA SHINICHI. Idiopathic Oropharyngeal and Esophageal Ulcers Related to HIV Infection Successfully Treated with Antiretroviral Therapy Alone. Intern. Med. [online] 2013 December, 52(3):393-395 [viewed 05 August 2014] Available from: doi:10.2169/internalmedicine.52.8709
  6. KIKENDALL JW. Pill-Induced Esophagitis Gastroenterol Hepatol (N Y) [online] 2007 Apr, 3(4):275-276 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099275
  7. SHARIFI A, DOWLATSHAHI S, MORADI TABRIZ H, SALAMAT F, SANAEI O. The Prevalence, Risk Factors, and Clinical Correlates of Erosive Esophagitis and Barrett's Esophagus in Iranian Patients with Reflux Symptoms Gastroenterol Res Pract [online] 2014:696294 [viewed 06 August 2014] Available from: doi:10.1155/2014/696294
  8. Vito D Corleto, Lidia D扐lonzo, Ermira Zykaj, Antonella Carnuccio, Francesca Chiesara, Cristiano Pagnini, Salvatore Di Somma, Gianfranco Delle Fave. A case of oesophageal ulcer developed after taking homeopathic pill in a young woman. World J Gastroenterol [online] 2007 April 14;13(14): 2132-2134 Available from: http://www.wjgnet.com/1007-9327/13/2132.asp
  9. PATRICK L. Gastroesophageal reflux disease (GERD): a review of conventional and alternative treatments. Altern Med Rev [online] 2011 Jun, 16(2):116-33 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21649454

Examination

Fact Explanation
Dental erosions Maybe due to chronic exposure of the oral cavity to gastric acid from GERD [1] and also from chronic self-induced vomiting (bulimia). [3]
Oral burn lesions Suggestive of ingestion of strong acids /alkalis. [7]
References
  1. PATRICK L. Gastroesophageal reflux disease (GERD): a review of conventional and alternative treatments. Altern Med Rev [online] 2011 Jun, 16(2):116-33 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21649454
  2. S. CADRANEL ,P, BAUTISTA CASASNOVAS. Caustic esophagitis: treatment and prevention. Journal du Pédiatre Belge [online] 201, 13: 27-29 [viewed 06 August 2014] Available from: http://www.bvksbp.be/downloads/common/paper/20111301/2011130101.pdf - Vol. 13 - Nr.1-2 27
  3. UHLEN MM, TVEIT AB, REFSHOLT STENHAGEN K, MULIC A. Self-induced vomiting and dental erosion - a clinical study. BMC Oral Health [online] 2014 Jul 29, 14(1):92 [viewed 06 August 2014] Available from: doi:10.1186/1472-6831-14-92

Differential Diagnoses

Fact Explanation
Erosive esophagitis (EE) EE is a complication of gastroesophageal reflux disease (GERD). [2] In GERD, esophageal erosion occurs due to the increased time that the esophageal tissue is exposed from the reflux of acidic stomach contents and the sensitivity of the esophageal tissue to those fluids. Common complaints are heartburn, regurgitation, and difficulty swallowing. Other manifestations caused from regurgitation or aspiration of gastric juice in GERD include chronic cough, asthma, dental erosions, recurrent pneumonitis, idiopathic pulmonary fibrosis, chronic sinusitis, posterior laryngitis, nocturnal choking, chronic hoarseness, otitis media and asthma. [3] Patients with GERD may develop more serious problems such as reflux esophagitis. Such patients may develop reparative erosive esophagitis, which may then lead into long-term complications such as Barrett's esophagus (BE) and esophageal adenocarcinoma. [4] All of these can be identified on endoscopy and confirmed with a biopsy.
Barretts esophagus (BE) BE is a complication of gastroesophageal reflux disease (GERD). [2] These patients are old in age [2] and usually present with symptoms of GERD or its complications (esophagitis, stricture, ulceration, dysplasia, adenocarcinoma). [1] Endoscopy identifies BE in long-term GERD-related symptoms or alarm symptoms. But patients may be asymptomatic and endoscopy findings may also be negative. [3]
Drug-induced esophageal ulcers Antibiotics are the most common agent of drug-induced esophageal ulceration with doxycycline being the commonest causative antibiotic; and other drugs include NSAIDs. The patients usually experience rapidly increasing chest pain on taking the medication just before going to bed. Lasts a few days and may gradually resolve. But in severe cases, patients may be unable to eat, and also complications such as stenosis, ulceration, hemorrhage, or perforation may occur but is uncommon. [8]
Esophageal ulcers associated with infections Infections at the esophagus can lead to ulceration of the esophagus and the most common etiological agents are: herpes simplex, cytomegalovirus, human immunodeficiency virus , tuberculosis and candida species. Esophageal tuberculosis: Commonly would present with dysphagia, cough, chest pain, fever and weight loss. In patients with a atrioesophageal fistula, they may present with hematemesis ;and upper gastrointestinal bleeding due to ulceration in the mid-esophagus caused from the erosion of tuberculous subcarinal lymph nodes. Primary tuberculosis of the esophagus is caused by lymphatic dissemination of the primary infection leading to reactivation of a focus. Secondary infection of the esophagus is caused from prolonged swallowing of sputum contaminated with bacilli from pulmonary tuberculosis or, by the formation of a fistula between the esophageal wall and a growing invasive tuberculous mediastinal lymph node. [5] Opportunistic infections have been occasionally seen in patients with primary HIV infection. Various combinations of co-infection of esophageal ulcers have been noted in HIV infected patients, commonest being candidiasis, CMV, and HSV infection.
Caustic or corrosive esophagitis Ingestion of caustic/corrosive agents such as strong acids/alkalis can cause severe burns causing ulceration, and perforation if the ulceration exceeds the muscle layer. Finally, causative stenosis and secondary stricture formation occurs. Patients usually have oropharyngeal lesions, but their absence does not exclude esophageal involvement and, hence esophageal lesions are excluded on endoscopy after stabilization of the patient. [7] Reports say that ingestion of alkali is more prevalent than that of acid in corrosive esophageal injuries [9]
Crohn's disease Esophageal Crohn's disease is found in 0.2% - 3% of patients with coexisting ileocolonic disease. In patients with a history of crohn's disease or with involvement of other segments of the digestive tract, diagnosis can be made with the typical endoscopic and radiographic appearance combined with histological examination. Isolated esophageal involvement in Crohn's disease is very rare, difficult, and late to diagnose and treat. Patients usually complain of progressive dysphagia of few months and the sudden appearance of heartburn. Severe dysphagia may occur secondary to stricture or perforation and/or fistula formation, requiring surgical intervention. Cases presenting with esophagus involvement alone usually have non-specific endoscopic findings therefore diagnosis is made on exclusion of other diseases. First phase: Inflammatory lesions, erosions and elongated ulcerations appear from edema of the esophageal mucosa. The patient has no significant symptoms of dysphagia or odynophagia. Second phase: Constrictions of the esophagus and stenosis appear usually on a section of over 1 cm, and the formation of mucosal bridges is observed. Third/end stage: The patient presents with progressive dysphagia and odynophagia with vomiting. Few patients can be cured through medication. But many patients present with severe complications such as severe strictures causing persistent dysphagia, hence requires esophageal dilatation and; fistula formation manifesting as recurrent mediastinal inflammation/abscess or pneumomediastinum. [6]
References
  1. MILIND R, ATTWOOD SE. Natural history of Barrett's esophagus World J Gastroenterol [online] 2012 Jul 21, 18(27):3483-3491 [viewed 06 August 2014] Available from: doi:10.3748/wjg.v18.i27.3483
  2. SHARIFI A, DOWLATSHAHI S, MORADI TABRIZ H, SALAMAT F, SANAEI O. The Prevalence, Risk Factors, and Clinical Correlates of Erosive Esophagitis and Barrett's Esophagus in Iranian Patients with Reflux Symptoms Gastroenterol Res Pract [online] 2014:696294 [viewed 06 August 2014] Available from: doi:10.1155/2014/696294
  3. PATRICK L. Gastroesophageal reflux disease (GERD): a review of conventional and alternative treatments. Altern Med Rev [online] 2011 Jun, 16(2):116-33 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21649454
  4. CHIH PC, YANG YC, WU JS, CHANG YF, LU FH, CHANG CJ. Overweight Associated with Increased Risk of Erosive Esophagitis in a Non-Obese Taiwanese Population PLoS One [online] , 8(11):e77932 [viewed 06 August 2014] Available from: doi:10.1371/journal.pone.0077932
  5. JAIN SS, SOMANI PO, MAHEY RC, SHAH DK, CONTRACTOR QQ, RATHI PM. Esophageal tuberculosis presenting with hematemesis World J Gastrointest Endosc [online] 2013 Nov 16, 5(11):581-583 [viewed 05 August 2014] Available from: doi:10.4253/wjge.v5.i11.581
  6. WANG WUPING, NI YUNFENG, KE CHANGKANG, CHENG QINGSHU, LU QIANG, LI XIAOFEI. Isolated Crohn’s disease of the esophagus with esophago-mediastinal fistula formation. Array [online] 2012 December [viewed 06 August 2014] Available from: doi:10.1186/1477-7819-10-208
  7. S. CADRANEL ,P, BAUTISTA CASASNOVAS. Caustic esophagitis: treatment and prevention. Journal du Pédiatre Belge [online] 201, 13: 27-29 [viewed 06 August 2014] Available from: http://www.bvksbp.be/downloads/common/paper/20111301/2011130101.pdf - Vol. 13 - Nr.1-2 27
  8. KIKENDALL JW. Pill-Induced Esophagitis Gastroenterol Hepatol (N Y) [online] 2007 Apr, 3(4):275-276 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099275
  9. ADEDEJI TO, TOBIH JE, OLAOSUN AO, SOGEBI OA. Corrosive oesophageal injuries: a preventable menace Pan Afr Med J [online] :11 [viewed 06 August 2014] Available from: doi:10.11604/pamj.2013.15.11.2495

Investigations - for Diagnosis

Fact Explanation
Barium swallow Initial assessment of dysphagia. [3]
Esophagogastroduodenoscopy (EGD) ,biopsy, histopathology and cytology. Golden standard for causality assessment. Endoscopy can identify Barrett's esophagus, esophagitis and malignancies causing ulceration. Biopsies are taken and histopathology, cytology and viral cultures will confirm the diagnosis with showing the presence of infectious agents and/or abnormal cell changes. More that three biopsies must be taken to rule out viral esophagitis. [1]
Psychiatric evaluation Deliberate ingestion of corrosive substances to cause self harm have been found in patients with psychiatric illness such as depression or psychotic illnesses that predisposed them to suicidal/para-suicidal tendencies. [2]
References
  1. SRILATHA PS, SUVARNA N, GUPTA A, BHAT G. Esophageal ulcer in a HIV-seropositive patient co-infected by herpes simplex and cytomegalovirus. Indian J Pathol Microbiol [online] 2011 Jan-Mar, 54(1):219-20 [viewed 06 August 2014] Available from: doi:10.4103/0377-4929.77420
  2. ADEDEJI TO, TOBIH JE, OLAOSUN AO, SOGEBI OA. Corrosive oesophageal injuries: a preventable menace Pan Afr Med J [online] :11 [viewed 06 August 2014] Available from: doi:10.11604/pamj.2013.15.11.2495
  3. LEVINE M S, RUBESIN S E. Radiologic investigation of dysphagia.. American Journal of Roentgenology [online] 1990 June, 154(6):1157-1163 [viewed 06 August 2014] Available from: doi:10.2214/ajr.154.6.2110721

Investigations - Followup

Fact Explanation
Esophagogastroduodenoscopy (EGD) Repeat EGD in 6 months for evaluation. [1]
References
  1. JAIN SS, SOMANI PO, MAHEY RC, SHAH DK, CONTRACTOR QQ, RATHI PM. Esophageal tuberculosis presenting with hematemesis World J Gastrointest Endosc [online] 2013 Nov 16, 5(11):581-583 [viewed 05 August 2014] Available from: doi:10.4253/wjge.v5.i11.581

Management - General Measures

Fact Explanation
Total parenteral nutrition (TPN) TPN can be administered in patients with odynophagia until it resolves. [4]
Advice GERD patients on lifestyle modifications Make dietary changes and reduce weight. Reduce or eliminate caffeine and alcohol consumption. Stop cigarette smoking. Keep head elevated during sleep. [1]
Proper intake of medications Insufficient intake of water predisposes the retention of pill within the esophagus facilitating mucosal injury. Pills taken before going to sleep are more in favour of its retention in the esophagus because in the supine position, effect of the gravity disappears and there is decreased salivation and swallowing during sleep. To prevent esophageal injury from this improper intake of medication, patients must be advised to take pills upright with a full glass of water, and avoid laying down for atleast 30 minutes. [2] [3]
References
  1. PATRICK L. Gastroesophageal reflux disease (GERD): a review of conventional and alternative treatments. Altern Med Rev [online] 2011 Jun, 16(2):116-33 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21649454
  2. KIKENDALL JW. Pill-Induced Esophagitis Gastroenterol Hepatol (N Y) [online] 2007 Apr, 3(4):275-276 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099275
  3. FERNANDOPULLE AN, NAVARATHNE NM. Oesophageal injury suspected to be due to doxycycline ingestion. Ceylon Med J [online] 2011 Dec, 56(4):162-3 [viewed 05 August 2014] Available from: doi:10.4038/cmj.v56i4.3897
  4. NICHOLAS J. V., SKIDMORE P. J., DOOLEY D. P.. Esophageal Ulceration Due to Cytomegalovirus Infection in a Patient with Acute Retroviral Syndrome. Clinical Infectious Diseases [online] 2002 January, 34(1):e14-e15 [viewed 06 August 2014] Available from: doi:10.1086/338024

Management - Specific Treatments

Fact Explanation
Nasogastric tube passage for stenting and for feeding, intravenous fluids, antibiotics; analgesic; H2- receptor blocker and proton pump inhibitors. Initial management in a patient with esophageal injury. [1]
Proton-pump inhibitors (PPIS) and/or sucralfate for pill-induced esophageal ulcer Discontinue pill causing ulceration. Supportive treatments: Proton-pump inhibitors (PPIS) and/or sucralfate. Rapid clinical recovery occurs in about 3-8 days and mucosal recovery in about 2-5 weeks. [2]
GERD medications Over-the-counter (OTC) antacids can give rapid, short-term relief from GERD symptoms. Histamine H2-receptor antagonists (ranitidine, famotidine, cimetidine, nizatidine) provides temporary relief. Prokinetics (cisapride, metoclopramide) causes increased esophageal and gastric peristalsis which helps in resolving the delayed esophageal clearance seen in GERD. Proton Pump Inhibitors (pantoprazole, lansoprazole, esomeprazole, omeprazole, rabeprazole) are the standard treatment of GERD. PPIs block the gastric acid pump of the parietal cells in the stomach. They provide faster relief than than prokinetics or H2-blocking agents and provide long-term healing of esophageal erosion (including Barrett’s esophagus). [3] In case of presence of H.pylori infection, administer triple therapies for 10-14 days. Treatment regimens consist of OAC for 10 days(omeprazole, amoxicillin, and clarithromycin); BMT for 14 days (bismuth subsalicylate, metronidazole, and tetracycline); and LAC either for 10 or 14 days (lansoprazole, amoxicillin, and clarithromycin). [7]
Antitubercular therapy Four-drug therapy (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for patients with esophageal tuberculosis is given for 6-9 months. [4]
Steroids, anti-retroviral therapy, anti-fungal therapy, anti-HSV therapy Steroids is the standard treatment of idiopathic esophageal ulcers but because of its immunosuppressive effects, opportunistic infections may occur. It has been found that antiretroviral therapy alone without steroids has shown to cause significant improvement in patients with idiopathic oropharyngeal and esophageal ulcers in HIV-infected patients. Antifungal therapy (fluconazole) can be used in the treatment of esophageal candidiasis. Anti-HSV therapy: HSV infection. [5] Antiviral therapy (ganciclovir): cytomegalovirus infection. [6]
References
  1. ADEDEJI TO, TOBIH JE, OLAOSUN AO, SOGEBI OA. Corrosive oesophageal injuries: a preventable menace Pan Afr Med J [online] :11 [viewed 06 August 2014] Available from: doi:10.11604/pamj.2013.15.11.2495
  2. DAG MUHAMMED SAIT, ABIDIN OZTURK ZEYNEL, AKIN IREM, TUTAR EDIZ, CIKMAM OZTEKIN, TANER GULSEN MURAT. Drug-induced esophageal ulcers: Case series and the review of the literature. Turk J Gastroenterol [online] 2014 July, 25(2):180-184 [viewed 06 August 2014] Available from: doi:10.5152/tjg.2014.5415
  3. PATRICK L. Gastroesophageal reflux disease (GERD): a review of conventional and alternative treatments. Altern Med Rev [online] 2011 Jun, 16(2):116-33 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21649454
  4. JAIN SS, SOMANI PO, MAHEY RC, SHAH DK, CONTRACTOR QQ, RATHI PM. Esophageal tuberculosis presenting with hematemesis World J Gastrointest Endosc [online] 2013 Nov 16, 5(11):581-583 [viewed 05 August 2014] Available from: doi:10.4253/wjge.v5.i11.581
  5. HAMADA YOHEI, NAGATA NAOYOSHI, HONDA HARUHITO, TERUYA KATSUJI, GATANAGA HIROYUKI, KIKUCHI YOSHIMI, OKA SHINICHI. Idiopathic Oropharyngeal and Esophageal Ulcers Related to HIV Infection Successfully Treated with Antiretroviral Therapy Alone. Intern. Med. [online] 2013 December, 52(3):393-395 [viewed 05 August 2014] Available from: doi:10.2169/internalmedicine.52.8709
  6. NICHOLAS J. V., SKIDMORE P. J., DOOLEY D. P.. Esophageal Ulceration Due to Cytomegalovirus Infection in a Patient with Acute Retroviral Syndrome. Clinical Infectious Diseases [online] 2002 January, 34(1):e14-e15 [viewed 06 August 2014] Available from: doi:10.1086/338024
  7. RAMAKRISHNAN K, SALINAS RC. Peptic ulcer disease. Am Fam Physician [online] 2007 Oct 1, 76(7):1005-12 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17956071