Esophagitis Flashcards
Esophagitis
General and types
Inflammation and irritation of the esophageal mucosa secondary to direct mucosal injury, infection, or an inflammatory process
Types:
Reflux esophagitis/GERD
Eosinophilic esophagitis
Infectious esophagitis
Drug-induced esophagitis
Gastroesophageal Reflux Disease (GERD)
general
Occurs at the result of incompetence of the lower esophageal sphincter allowing reflux of gastric contents into the esophagus
Generalized loss of sphincter tone
Recurrent inappropriate transient relaxations of the sphincter triggered by gastric distention
Common condition
10-20% of adults
Occurs frequently in infants
Left image (normal): The LES, a structure at the gastroesophageal junction, maintains a high-pressure zone between the esophagus and the stomach. This prevents the reflux of gastric contents. The LES relaxes transiently in response to meals.
Right image (GERD): An incompetent LES (lower baseline pressure) and increased frequency of TLESRs are among the factors causing GERD.
The esophageal and gastric fundi should be at an acute angle to each other (about 50 degrees, the so-called angle of His) for optimal barrier function
A: Normal anatomy
B: Widening of the esophagogastric angle
GERD
RF
Cigarette smoking
Obesity
Hiatal hernia
Foods & Drinks:
Alcoholic and caffeinated beverages
Fried or fatty foods
Citrus or spicy foods
Chocolate
Red sauce
Medications that decrease LES pressure:
Nitrates
Calcium channel blockers
also people who lay down 2-3 hours after eating.
GERD
complications (4)
Peptic esophageal ulceration
Esophageal strictures
Barrett esophagus
Replacement of normal squamous epithelium of the distal esophagus with metaplastic columnar epithelium during the healing phase of acute esophagitis
Esophageal adenocarcinoma
Malignancy that often arises from Barrett esophagus
GERD
infant clin man
Vomiting
Irritability
Anorexia
Symptoms of chronic aspiration
GERD
Adults - typical presentation
Retrosternal heartburn (pyrosis)
30-60 minutes after meals or upon reclining
Regurgitation
Sour or bitter taste in the mouth
GERD
Adults - atypical presentation
Dysphagia/odynophagia (esophagitis has developed)
Globus sensation
Hoarseness
Sore throat
Chronic cough
Weight loss
GERD Tx
Mild and intermittent symptoms (fewer than two episodes per week) and no evidence of erosive esophagitis/atypical sx
Lifestyle and dietary modification and
As needed, low-dose histamine 2 receptor antagonists (H2RAs)
Famotidine 20 mg BID
Cimetidine 400 mg BID
GERD
Dx for Atypical Sx
ENDOSCOPY first to rule out more serious symptoms
GERD Tx
Regular, typical symptoms
Empiric and persistent/refractory
Initial diagnostic studies are not warranted
Empiric treatment:
Twice daily H2-blocker or once-daily proton pump inhibitor (PPI) for 8 weeks
Persistent/refractory symptoms:
Maximize PPI dosing for 8 weeks
No improvement with empiric treatment or symptoms of complications…time to refer to GI
Endoscopy with cytologic washings and/or biopsy of abnormal areas
GERD
Esophagogastroduodenoscopy (EGD)
type of visualization
First-line endoscopic test for patients with alarm symptoms or refractory symptoms
Allows for direct inspection of the esophagus and gastric mucosa for objective evidence of GERD (erosive esophagitis or Barrett esophagus)
- Class A-D grading system for the severity of reflux esophagitis
- Patients with severe erosive esophagitis (Class C and D) on initial endoscopy should undergo a follow-up endoscopy after a two-month course of twice daily PPI therapy to assess healing and rule out Barrett’s esophagus
Class A = mild esophagitis
Class D = severe esophagitis
Evidence of mucosal healing on repeat endoscopy → decrease PPI therapy to once daily
GERD
Ambulatory pH monitoring
Allows for detection of gastroesophageal reflux
Used to confirm the diagnosis and check the adequacy of treatment
Performed for 24 or 48 hours
Measures the frequency of thepHdropping below < 4.0
Ambulatory pH monitoring
reliable detects (3)
Pathologic acid exposure
Frequency of reflux episodes
Correlationof symptoms with reflux episodes
Ambulatory pH monitoring
Indications/Forpatientswith (3)
Extraesophageal symptoms
GERDrefractory to medications
No endoscopic findings
GERD
Lifestyle and dietary modification
Elevation of the head of the bed about 6 inches
Encourage weight loss
lay on LEFT side (not R side)
Avoiding the following:
Eating within 3 hours of bedtime
Strong stimulants of acid secretion (coffee, alcohol)
Specific foods (fatty foods, chocolate, red sauces)
Smoking
Medications that decreased LES pressure
IMPLEMENTED FOR ALL PTS
GERD
Antacids
Do not treat the disease, but balancespH
Useful in intermittent disease only
Provides relief with five minutes; duration of 30-60 minutes
Examples:calcium carbonate, aluminum hydroxide
GERD
H2-blockers
Indicated for mild symptomatic GERD
Can be added at bedtime forpatientson proton-pump inhibitors (PPIs) with nocturnal symptoms
Decreases acidsecretion by competitively blockingH2 receptorsin gastricparietal cells
Examples:famotidine,cimetidine
Proton pump inhibitor (PPI)
Block gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the luminal surface of the parietal cell membrane
Heals esophagitis, if present
Only partial response to once-daily dosing → may ↑ to the PPI to twice daily, add a H2-blockers, or add on-demand antacid therapy
May be given long-term at the lowest possible dose to prevent symptoms
GERD
Sucralfate
(aluminum sucrose sulfate)
Surface agent
Adheres to the mucosal surface, promotes healing, and protects from peptic injury
Mechanisms of action is not completely understood
Treatment option during pregnancy
Can be used short term along with PPI therapy
PPI examples and doses
All are equally effective
Omeprazole 20 mg daily
Pantoprazole 40 mg daily
Esomeprazole 40 mg daily
Lansoprazole 30 mg daily
GERD
Surgery options
Endoscopic dilation
Repeated as needed for esophageal strictures
Antireflux surgery
Laparoscopic fundoplication
Gastric fundusis wrapped around the loweresophagus
Indicated for patients with grade C or D esophagitis, large hiatal hernias, and those who cannot tolerate drug therapy
Barrett esophagus
general
Precancer
Precursor to adenocarcinoma of the esophagus
Seen in ~15% of patients with GERD
Risk factors:
Male
Age ≥ 50 years
Obesity
Symptoms ≥ 5 years (untreated or sub-optimal treatment)
Endoscopic surveillance for malignant transformation is recommended every 3-5 years in nondysplastic disease
Barrett esophagus
Endoscopic ablative therapy
Indicaron and options (4)
For confirmed low-grade dysplasia
Mucosal resection
Photodynamic therapy
Cryotherapy
Laser ablation
Eosinophilic Esophagitis (EoE)
general
Chronic allergic inflammatory disease characterized by the presence of eosinophils in the esophageal tissue
Strong association with allergic conditions - food allergies, environmental allergies, asthma, and atopic dermatitis
Common age of presentation: 20-30 years
Prevalence is increasing
Change in epidemiology
Increased awareness and detection
EOE
Patho
Type 2 T-helper cell-mediated systemic response to food and environmental allergens
Release of cytokines: IL-5, IL-13, IL-4, and exotaxin
EOE
Infants & children Clin man
Failure the thrive
Vomiting
Abdominal pain
Reflux
Heartburn
EOE
Adolescents & Adults
Clin man
Solid food dysphagia
15% of patients being evaluated for dysphagia with endoscopy are found to have eosinophilic esophagitis
Heartburn
Chest pain
Often centrally located and may not respond to antacids
Food bolus impaction
History of food impaction is present in up to 54% of patients
EOE
Dx
Clinicopathologic diagnosis requiring specific symptoms and pathologic changes in the esophageal mucosa:
Symptoms related to esophageal dysfunction
Eosinophil-predominant inflammation on esophageal biopsy (proximal and distal), characteristically consisting of ≥ 15 eosinophils per high power field (HPF)
Exclusion of other causes that may be responsible for or contributing to symptoms
Persistence of esophageal eosinophilia on repeat biopsy after an adequate trial (8 weeks) of twice-daily PPI therapy confirms the diagnosis
Elevated serum IgE level in 50-60% of patients
eosinophils should NOT be in esophagus
EOE
endoscopy
Variety of morphologic features in the esophagus associated with eosinophilic esophagitis
Mucosal fragility
Whitish papules (representing eosinophil microabscesses)
Linear furrows
Stacked circular rings - “trachealization”
Strictures
do biopsy here.
EOE
Barium swallow
Not sufficient for the diagnosis of EoE
Helps characterize anatomic abnormalities and provide information on the length and diameter of strictures
EOE
Tx
Chronic condition, so the goal of treatment is to reduce the inflammatory response
Inhaled or oral suspension of a corticosteroid for 8 weeks
No formulation of topical glucocorticoids has been approved specifically for eosinophilic esophagitis in the United States
fluticasone (Flovent)
budesonide (Pulmicort)
Acid suppression
Proton pump inhibitors (PPIs)
Initial treatment for eight weeks
One tablet PO daily (if symptoms fail to improve after four weeks of therapy, increase the dose to one tablet PO twice daily)
One tablet PO twice daily
allergy testing is also a good move
EOE
Dupilumab (Dupixent)
BEST for EOE
May 2022 - Only monoclonal antibody FDA approved for patients 12 years and older, weighing at least 40 kg
January 2024 – FDA approval to treat patients with EoE aged 1 year and older, weighing at least 15 kg
EOE
Esophageal dilation
Dilation goal
Effective for relieving dysphagia
No effect on underlying inflammation
Often reserved for patients who have failed more conservative therapy or who have high-grade strictures
Dilation is limited to 3 mm or less per session
Dilation goal of 15-18 mm
Potential complications:
Deep mucosal tears
Esophageal perforation
EOE
Elimination diets
Allergy testing to identify foods that cause allergy and therefore should be avoided
6-food elimination: Cereals, milk, eggs, fish/seafood, peanuts, and soy
