What Is Oesophagitis

Overview

Oesophagitis is the inflammation of the oesophagus (the muscular tube carrying food from the mouth to the stomach). Oesophagitis is mostly encountered in adults rather than children and it can be of different forms.¹ Oesophagitis can be very painful affecting your day-to-day life; however, ​with rapid diagnosis and proper treatment, oesophagitis prognosis is usually good.¹

Signs and symptoms of oesophagitis 

Signs and symptoms of oesophagitis may vary in their prevalence/ severity according to the type of oesophagitis. However, the most common symptoms of oesophagitis are:

• Chest pain can be either retrosternal (behind) or midsternal (middle) of the breastbone
• Dyspepsia (heartburn)
• Odynophagia (pain during swallowing)
• Dysphagia (swallowing difficulties)

Other symptoms include nausea, bloating, upper abdominal discomfort, and fullness.^1,2,3 Some types of oesophagitis may have additional symptoms characteristic of its pathophysiology.

Types of oesophagitis 

There are different types of oesophagitis. Each type is primarily linked to the underlying cause as well as the risk factors.

Reflux oesophagitis

The most common cause of reflux oesophagitis is Gastroesophageal Reflux Disease (GERD) or acid reflux disease which affects at least 20% of the population.² This occurs when irritants like gastric acid (digestive acid of the stomach), pepsin, and bile flow back into the oesophagus, causing a chemical burn in the mucosal lining. 

This leads to inflammation, erosion, and sometimes ulceration.¹ When left untreated, GERD can progress into serious complications, including oesophagitis and Barrett’s oesophagus, where the normal cells lining the mucosal lining of the oesophagus start to change in shape and structure to become more like the cells lining the small and large intestines.^4,5 

Another possible cause of Reflux oesophagitis is an eating disorder called Bulimia Nervosa, where frequent vomiting is prevalent resulting in the acid burn of the oesophagus and hence oesophagitis.^2,3

Infectious oesophagitis

Where oesophagitis is triggered by an infection in the oesophagus caused by either bacteria (ex. yeast), virus (ex. herpes virus, cytomegalovirus), parasite, or fungus.⁶ Usually occurs in immunocompromised people whose immune system is weak. This includes but is not limited to patients:

• with HIV infection
• who use long-term steroid medications
• who have had organ transplants 
• who have been treated with chemotherapy for cancer
• of advanced age
• with systemic diseases (such as diabetes, adrenal dysfunction, and alcoholism)

Bacterial oesophagitis is the least common infectious oesophagitis, whereas fungal oesophagitis is the most common one followed by viral oesophagitis. The most encountered form of fungal oesophagitis is Candida oesophagitis caused by the fungus Candida albicans. The most common cause of viral oesophagitis is Human-immunodeficiency virus (HIV), followed by cytomegalovirus (CMV).^2,5,6

Odynophagia and dysphagia are prominent symptoms of infectious oesophagitis.⁵ In some circumstances, patients may be asymptomatic, while others may experience some additional symptoms characteristic of oesophagitis. These include fever and sepsis, hematemesis, anorexia, weight loss, and abdominal epigastric pain.¹

Pill-induced oesophagitis 

Some medications cause irritation of the oesophagal mucosa either by direct toxic activity or through the production of caustic acidic or alkaline solutions. Prolonged exposure to these medications results in oesophagitis. Examples of these medications include:

• Antibiotics (ex. doxycycline, tetracycline)
• Non-steroidal anti-inflammatory drugs (ex. aspirin, ibuprofen, naproxen)
• Iron supplements (ferrous sulfate)
• Osteoporosis medications (such as alendronate or risedronate)
• Potassium chloride^1,3,6

Eosinophilic oesophagitis

As the name suggests, it is caused by the high number of a type of white blood cells called eosinophils. These are produced in response to an active inflammation or an allergic reaction.³

Although the pathogenesis of eosinophilic oesophagitis is not completely defined, significant evidence suggests it is a result of an allergic disorder induced by either food or air allergy.⁷ 

In addition to the normal symptoms of oesophagitis, these patients may experience eating difficulties which have a significant impact on their life quality. Adults with eosinophilic oesophagitis present with characteristic rings in the oesophagus, shown in the upper GI endoscopy.⁷

Radiation and chemoradiation oesophagitis 

It is one of the most common acute adverse reactions of radiotherapy (received as part of cancer therapy for breast, lung, and other lymphomas).⁸ Radiation consists of high-energy electrons that cause DNA damage and cell death, interfering with proliferation. 

Small doses result in acute injury and minor alterations in the mucosal formation. However, larger doses lead to chronic injury where extensive regions of the mucosa are affected, compromising blood flow into the small vessels. Progressive injury can result in strictures, ulceration, fistula formation, and even perforation.

Usually, symptoms can present after two to three weeks after the initial therapy. These include dysphagia, throat pain, and the sensation of food being stuck.⁸ To alleviate the symptoms of chest pain, topical application of viscous solutions containing lidocaine or steroids may be used. Parenteral nutrition may be required with severe oesophagitis leading to hospitalization and treatment interruptions.⁶

Causes of oesophagitis 

Different causes lead to different types of oesophagitis. The main causes includes:

• Acid Reflux 
• Infections (fungal/viral/bacterial)
• Food/ air allergies
• Medication 
• Radiation
• Chemotherapeutic agents
• Autoimmune diseases⁶

Management and treatment for oesophagitis 

It is very important to identify what is irritating your oesophagus and hence try and stop it. This might require various lifestyle changes or medications, depending on the cause. This will help the natural healing process to start and take over.²

Treatment usually includes changes to both medications and lifestyle.

Medications

 Acid-blocking medications: proton-pump inhibitors (PPIs), Antacids, and H2 blockers can help treat acid reflux. There are over-the-counter and prescription-strengths options.

Anti-inflammatory drugs: For eosinophilic oesophagitis, healthcare providers recommend a liquid steroid formula that coats the oesophagus and relieves inflammation without causing the side effects that you might get from the pill.

Antifungal medication for fungal infections such as candida.

Antiviral medications for viral infections, such as herpes.

Monoclonal antibodies are synthetic versions of proteins that communicate with your immune system to stop inflammation. One example of monoclonal antibody is Dupilumab which has been recently approved by the U.S. FDA to treat eosinophilic oesophagitis.

Lifestyle recommendations

Dietary changes: Try to identify and avoid the foods and drinks that trigger acid indigestion and reflux or that trigger an allergic reaction.

Medication changes: Ask your healthcare provider about switching medications that cause oesophagitis or consider switching to a liquid form. If you have to take a pill, take it with a full glass of water.

Evening routine: Try to have dinner at least three hours before bedtime to give it a chance to digest before you lie down. Elevating the head to 30-45 degrees can help with nocturnal symptoms of acid reflux including the night cough, sore throat, and voice hoarseness.

Commonsense self-care: Quit smoking, lose weight, and avoid fatty and spicy foods, coffee, carbonated drinks, chocolate, and alcohol. Moreover, eating smaller meals and the maintenance of a clear liquid or soft puree diet during treatment can help reduce acid reflux, ease the symptoms, and accelerate healing time.^2,7

Diagnosis

Approach used for diagnosis differs from case to case according to the symptoms experienced by the patient.¹

History and clinical examination can be enough for the diagnosis of reflux or pill-induced oesophagitis. However, to differentiate between the subtypes of oesophagitis, endoscopy and biopsy examination are required.⁷

The healthcare provider can often diagnose oesophagitis based on your symptoms. Since the most common type of oesophagitis is reflux oesophagitis, the healthcare provider might prescribe acid-blocking medications like PPIs to see if they help. If it does, they assume it is reflux oesophagitis. If it doesn’t, initial upper endoscopy (esophagogastroduodenoscopy [EGD]) can be performed to reveal more diagnostic information such as inflammatory characteristics, ability to obtain samples for pathologic examination, cytologic examination, and viral and bacterial cultures.²

The endoscopic appearance of the mucosal lesions can help with diagnosis. In those with suspected eosinophilic oesophagitis, endoscopy may reveal white exudates or papules, red furrows, corrugated concentric rings, and strictures Endoscopic signs of candidiasis suggest infectious oesophagitis are small, diffuse, linear, yellow-white (cheese-like) plaques adherent to the mucosa. CMV oesophagitis is characterized by several large, shallow, superficial ulcerations. HSV oesophagitis results in multiple small, deep ulcerations.⁷ 

Risk factors

Each type of oesophagitis has its own risk factors. For example:

• Reflux oesophagitis: Eating immediately before going to bed
• Excessively large and fatty meals
• Smoking
• Extra weight, including from pregnancy¹

Complications

Untreated oesophagitis can lead to changes in the structure of the oesophagus.

Possible complications include:

Ulcers in the oesophagus: which are open sores that can cause pain and GI bleeding If left untreated can form a hole in the oesophagus (gastrointestinal perforation), increasing the risk of more serious complications such as septicemia.

Esophageal stricture: Scarring or narrowing of the oesophagus, known as stricture.

Severe/serious swallowing difficulties can lead to dehydration, weight loss, and malnutrition.

Barrett’s oesophagus, also called intestinal metaplasia where the tissues lining your oesophagus adapt to constant inflammation by changing to resemble the lining of your intestines. This can be a precursor to oesophagal cancer.²

FAQs

How can I prevent oesophagitis?

Make the necessary lifestyle changes (discussed in the treatment and management section)

• Quit smoking and drinking alcohol
• Lose weight
• Eat small meals, especially nighttime
• Make sure dinner is at least 3 hours before bedtime

How common is oesophagitis

Reflux oesophagitis is the most common type of oesophagitis. Other types are relatively rare unless the associated risk factors are present. Epidemiologists say that as many as 1% suffer from reflux oesophagitis.⁵

When should I see a doctor

Difficulty or pain in swallowing, persistent cough with/without blood, unexplained fever.

Summary

For people with a high risk for oesophagitis, self-care plays a crucial role in the prevention of disease onset. Usually, the prognosis of any medical condition depends on the severity of the underlying disease. However, generally, with early diagnosis and proper treatment, there is a higher success rate in treating oesophagitis.¹