Esophageal Infections and Ingestions

Question 1

Histology Slide: pseuodhyphae: candida. Due to low CD4 count or recent exposure to antibiotic

Answer 1

Question 2

Candida Esophagitis DDX

Answer 2

Plaque like material mimicking candida can be found in:
- Reflux esophagitis
- EOE
- CMV
- Herpes Simplex esophagitis
- Pill esophagitis

Question 3

Risk factors for Candida Esophagitis include:

Answer 3

• HIV
• Steroid treatment (EOE and Asthma)
• Chemotherapy
• Exposure to broad spectrum antibiotics
• Organ transplantation

Question 4

Treatment of Candida Esophagitis

Answer 4

• Fluconazole: inhibits fungal cytochrome system, alters cell membrane permeability.
• Echinocandins: caspofungin, micafungin, anidulafungin

Question 5

herpes simplex: discrete ulcerations, ulcerations

Answer 5

Question 6

Herpes Simplex

Answer 6

Question 7

CMV Esophagitis

Answer 7

Question 8

Ingestions

Answer 8

Majoirty are accidental and under 5 years of age.
Sxs: stridor, chest pain, drooling.
household cleaning agents, analgesics, cosmetics and personal hygiene are the 3 most common.
household bleach 5-10% is harmless
sodium hydroxide: drain and oven cleaners: severe.
Hair relaxers: pain and erythema of the mouth.

Question 9

Caustic Agents Pathophysiology

Answer 9

Injury depends on: pH, concentration, tissue contact time, amount and form (liquid vs gel vs solid).
Acidic agent (pH<2). Coagulation necrosis, formation of eschar limits injury.
Alkaline agent (pH>12): Liquefaction necrosis and saponification: causes deep injury. Vascular thrombosis causes tissue ischemia.

Question 10

Endoscopy

Answer 10

-12-28 hours after ingestion
- avoid 5-15 days after ingestion
- minimize air insufflation
- grade and categorize injury
- if suspect perforation: consult surgery.

Question 11

Management of ingestions

Answer 11

-secure airway,
- don’t scope if concern for gastric perforation.
- Treat with PPI for first month.
- Antibiotics and steroids: controversial.
Long term: manage strictures (EGD or surgery).

Question 12

Stricture management

Answer 12

• Dilations: 3 weeks after ingestion
  -intra-lesional steroids
  -topical mitomycin C
  -consider stents.
• Long term risk of cancer greatly increased.

Question 13

Pill Esophagitis

Answer 13

• pills usually lodge at junction of proximal and middle thirds of esophagus.
  -retrosternal pain, odynophagia, and dysphagia can develop several hours after pill ingestion.
  Endoscopy: discreet ulcer with surrounding normal esophagus.
  -Hematemesis and perforation have been reported