Esophagitis

  • Medical Author:
    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

  • Medical Editor: Bhupinder Anand, MD
woman with abdominal pain

Facts and definition of esophagitis

  • Esophagitis is defined as inflammation of the esophagus, which is the tube that connects the throat to the stomach.
  • Esophagitis can be caused by infection, irritation of the esophagus, or inflammation of the lining of the esophagus.
  • There are several types of esophagitis: reflux esophagitis, infectious esophagitis, Barrett's esophagus, eosinophilic esophagitis, Behçet's syndrome (also called Behçet's disease), graft-versus-host disease, and cancer esophagitis. 
  • Signs and symptoms of esophagitis include
  • Esophagitis is treated by a gastroenterologist, a specialist in conditions of the gastrointestinal tract.
  • Tests to help diagnose esophagitis include esophagogastroduodenoscopy (EGD), esophageal manometry, and an upper GI series or barium swallow.
  • Treatment for esophagitis depends on its cause. It may be treated with medications, endoscopy, stretching (dilatation) of the esophagus, surgery, and lifestyle changes.
  • Diet can often help reduce symptoms of esophagitis. The GERD diet is aimed at reducing acid reflux, the main cause of esophagitis.
  • Complications of esophagitis include bleeding, ulcers, chronic scarring, difficult or painful swallowing, and malnutrition. Barrett's esophagus is a complication that increases the risk of esophageal cancer.
  • The prognosis for esophagitis depends on the underlying cause. Esophagitis caused by infection or inflammation is generally treatable and most people can recover fully. Esophagitis caused by reflux can recur frequently. Many people with GERD develop Barrett's esophagus, which increases the risk for cancer. The outlook for patients with eosinophilic esophagitis is favorable. It is a chronic, relapsing condition, but not usually life-threatening. Achalasia is progressive, but treatable.

What is esophagitis?

Esophagitis is a term used to describe inflammation of the esophagus, which is the tube that connects the throat to the stomach. There are several types of esophagitis depending on the cause. Esophagitis can be caused by infection, irritation of the esophagus, or inflammation of the lining of the esophagus.

Quick GuideDigestive Disorders: Common Misconceptions

Digestive Disorders: Common Misconceptions

Reflux Laryngitis Symptoms and Signs

Reflux laryngitis is inflammation of the voice box that is caused by stomach acid backing up into the esophagus. Signs and symptoms of reflux laryngitis include:

  • GERD (acid reflux)
  • Heartburn
  • Obesity
  • Chronic hoarseness
  • Asthma

What are the signs and symptoms of esophagitis?

Symptoms of esophagitis include:

  1. Difficult and/or painful swallowing
  2. A feeling of food getting stuck on the way down
  3. Heartburn
  4. Acid reflux
  5. Unpleasant taste in mouth
  6. Sore throat
  7. Hoarseness
  8. Cough
  9. Mouth sores
  10. Nausea
  11. Vomiting
  12. Abdominal pain or indigestion
  13. Chest pain, in the middle of the chest, often radiating to the back, usually associated with swallowing or occurring soon after a meal
  14. Bad breath (halitosis)

What are the types of esophagitis?

There are several types of esophagitis.

  • Reflux esophagitis is caused by a reflux of stomach acid into the esophagus. This can lead to erosive esophagitis.
  • Infectious esophagitis is caused by bacteria, viruses, or fungus.
  • Barrett's esophagus results from untreated inflammation of the esophagus that can cause changes in the type of cells that make up the inner lining (mucosa) of the esophagus. Barrett's esophagus increases the risk for esophageal cancer.
  • Eosinophilic esophagitis is inflammation of the esophagus due to an increase in the number of a type of white blood cells (eosinophils) in the lining of the esophageal wall. It is considered an allergic/immune condition. This leads to dysmotility of the esophagus (the muscles do not work properly to move food through) and difficulty in swallowing. Causes of eosinophilic esophagitis include food allergies, gastroesophageal reflux disease (GERD), parasitic diseases, or inflammatory bowel diseases.
  • Behçet's syndrome (also called Behçet's disease) is a form of vasculitis that can cause ulcers in the mouth, esophagus and other parts of the body. This disease is rare in the U.S.
  • Graft-versus-host disease is a complication that can occur after a transplant (usually bone marrow transplant) when the newly transplanted cells attack the recipient's body. Esophagitis may occur in this condition.
  • Cancer esophagitis may be a symptom of cancer of the esophagus, or metastatic cancer (cancer that started in another part of the body and then spreads to the esophagus).

What causes esophagitis?

Esophagitis can be caused by infection or irritation of the esophagus.

Infections of the esophagus can be caused by bacteria, viruses, or fungi, including:

  • Candida, a yeast infection. This is more common in patients with weakened immune systems, such as those with diabetes, HIV/AIDS, patients undergoing chemotherapy, or people who are taking antibiotics or steroids.
  • Herpes, a viral infection. It may develop in the esophagus when the body's immune system is weak.

One of the main causes of esophageal irritation is reflux of stomach acid. There are several causes for reflux:

  • GERD (gastroesophageal reflux disease): weakness or dysfunction of the muscle that keeps the stomach closed (sphincter) can allow stomach acid to leak into the esophagus (acid reflux), causing irritation of the inner lining. Also called GERD esophagitis - in severe cases it can become erosive esophagitis (this also may be referred to as ulcerative esophagitis).
  • Vomiting: when vomiting is frequent or chronic it can lead to acid damage to the esophagus. Excessive or forceful vomiting may cause small tears of the inner lining of the esophagus, leading to further damage.
  • Hiatal hernia: This abnormality occurs when a part of the stomach moves above the diaphragm producing a small abnormal pouch, or hiatal hernia, which can lead to excess acid refluxing into the esophagus.
  • Achalasia: This is a disorder where the lower end of the esophagus does not open normally, and as a result food can get stuck in the esophagus or is regurgitated. People with achalasia have a higher than normal risk of esophageal cancer.

Medical treatments for other problems can also cause esophageal irritation.

Surgery, including certain types of bariatric (weight loss) surgery, can lead to increased risk of esophagitis. Medications such as aspirin and other anti-inflammatory drugs can irritate the lining of the esophagus, and also cause increased acid production in the stomach that can lead to acid reflux.

Drug-induced esophagitis occurs when large pills are taken with too little water or just before bedtime and they dissolve or get stuck in the esophagus, causing irritation. Radiation to the chest (thorax), for cancer treatment can cause burns leading to scarring and inflammation of the esophagus.

Other causes of esophageal irritation:

  • Swallowing of foreign material or toxic substances
  • Diets high in acidic foods or excessive caffeine
  • Smoking

Quick GuideDigestive Disorders: Common Misconceptions

Digestive Disorders: Common Misconceptions

What are the grades of esophagitis?

There are number of grading systems used to evaluate the severity of the disease. Savary-Miller and the Los Angeles Classification System are two of the commonly used grading systems.

Savary-Miller:

  • Grade I: one or more supravestibular, non-confluent reddish spots, with or without exudate
  • Grade II: erosive and exudative lesions in the distal esophagus which may be confluent, but not circumferential
  • Grade III: circumferential erosions in the distal esophagus, covered by hemorrhagic and pseudomembranous exudates
  • Grade IV: presence of chronic complications such as deep ulcers, stenosis, or scarring with Barrett's metaplasia

Los Angeles Classification System grades reflux esophagitis:

  • Grade A: One (or more) mucosal break no longer than 5 mm that does not extend between the tops of two mucosal folds
  • Grade B: One (or more) mucosal break more than 5 mm long that does not extend between the tops of two mucosal folds
  • Grade C: One (or more) mucosal break that is continuous between the tops of two or more mucosal folds but which involve less than 75% of the circumference
  • Grade D: One (or more) mucosal break which involves at least 75% of the esophageal circumference

Which specialties of doctors treat esophagitis?

A primary care provider (PCP) such as a family medicine specialist, an internist, or a child's pediatrician, may initially diagnose esophagitis. For further treatment you will likely be referred to a gastroenterologist, a specialist in disorders of the digestive system.

How is esophagitis diagnosed?

A gastroenterologist may order specialized tests to look for the cause and extent of the esophagitis. These tests include:

  • Esophagogastroduodenoscopy (EGD): An endoscope is used to directly examine the esophagus, stomach and first part of the intestines. In addition, tissue samples can be obtained (biopsy) to assess the severity of the damage to the esophagus.
  • Esophageal manometry: this test is used to measure the pressure inside the lower part of the esophagus. A thin, pressure-sensitive tube is passed through the mouth or nose and into the stomach, which is then pulled slowly back into the esophagus. Patients are asked to swallow, and the pressure of the muscle contractions is measured along several sections of the tube.
  • Upper GI series or barium swallow is a test where X-rays are taken of the esophagus after drinking a barium solution. Barium coats the lining of the esophagus and appears white on an X-ray, and can show the location and extent of damage to the esophagus.

What is the treatment for esophagitis?

Treatment for esophagitis depends on its cause.

  • If esophagitis is caused by an infection, it is treated with medications to eliminate the infection.
  • If esophagitis is caused by acid reflux it is treated with medications to reduce or block acid production, for example, heartburn drugs.
  • If esophagitis is due to a medical procedure the patient may need to be on acid-blocking medications for a long time.
  • If the cause of esophagitis is due to taking medications, the patient may need to change those medications. Always consult a doctor before stopping or changing medication.

If esophagitis is diagnosed early enough, medications and dietary or lifestyle changes are often enough to allow the body to heal. If the damage is severe or leads to scar tissue causing difficulty swallowing, more invasive treatments may be necessary.

  • Endoscopy can be used to remove any lodged pill fragments, food, or foreign bodies stuck in the esophagus. Stretching (dilatation) of the esophagus can also be done as part of the endoscopy procedure.
  • Surgery may be necessary to remove any damaged portions of the esophagus. In the case of Barrett's esophagus, where the risk of cancer is increased, surgery might be the treatment of choice.
  • Eosinophilic esophagitis is treated with gentle stretching of the esophagus (dilatation) and medications to decrease white blood cells (eosinophils) in the lining of the esophagus.
  • Achalasia may be treated with stretching of the esophagus (dilatation) when oral medications fail to improve symptoms.

Lifestyle changes that may alleviate symptoms of GERD and esophagitis include:

  • Stop smoking
  • Remain upright while eating and for a time (about 2-3 hours) afterwards
  • Take small bites and chew food slowly
  • Avoid eating within 3 hours of bedtime or laying down
  • Raise the head of the bed by 4 to 6 inches (put blocks or a foam wedge under the head of the bed; don't use pillows as this can put pressure on the abdomen)
  • Lose weight
  • Wear loose clothing
  • Avoid aspirin or ibuprofen (Advil, Motrin)

Quick GuideDigestive Disorders: Common Misconceptions

Digestive Disorders: Common Misconceptions

What about esophagitis and diet?

Diet is often a key to reducing the symptoms of esophagitis. The GERD diet is aimed at reducing acid reflux, the main cause of esophagitis.

  • Eat low fat, high protein meals
  • Avoid fatty foods
  • Avoid spicy foods
  • Avoid acidic foods and beverages such as citrus and tomatoes
  • Avoid foods that may trigger or worsen heartburn including chocolate, mint, onions or garlic
  • Eat smaller meals, more frequently
  • Eat soft foods that are easily digested
  • Stop eating before you feel full
  • Avoid coffee or tea (even decaffeinated), alcohol, and soda

What options are there for pain relief for esophagitis?

Many over-the-counter medications can help neutralize stomach acid and provide short-term relief for the pain of esophagitis caused by acid reflux. Do not take these medications long-term. See a doctor if symptoms persist for more than two weeks.

Pain medications and medications that decrease inflammation such as corticosteroids can be used as adjuncts in the treatment of any inflammatory cause of esophagitis.

What are the complications of esophagitis?

If untreated, esophagitis caused by GERD can lead to bleeding, ulcers, and chronic scarring. This scarring can narrow the esophagus, eventually interfering with the ability to swallow.

A major complication, which occurs in a significant portion of people with chronic or longstanding GERD, is Barrett's esophagus, which increases the risk of esophageal cancer. A very few of those who develop Barrett's esophagus will develop esophageal adenocarcinoma.

Severe esophagitis may lead to difficult or painful swallowing, and malnutrition.

Can esophagitis be prevented?

Some types of esophagitis can be prevented.

  • Esophagitis caused by GERD may be prevented by changes in lifestyle and diet.
  • Proper oral hygiene can aid in prevention of esophagitis caused by the Candida yeast.
  • Take all pills with plenty of water, and in an upright position.

What is the prognosis for a person with esophagitis?

  • The prognosis for esophagitis often depends on the underlying cause.
  • Esophagitis caused by infection or inflammation is generally treatable with medications, diet or behavioral changes and in some cases, surgery. Most people can recover fully, while some have chronic inflammation that is managed with long-term medical treatment.
  • Esophagitis caused by reflux, while often manageable, can recur frequently. Many patients who have reflux require medication or other treatment to prevent relapses.
  • A significant percentage of people with GERD go on to develop Barrett's esophagus. Very few of patients with Barrett's esophagus develop cancer. A gastroenterologist should monitor patients who have Barrett's esophagus.
  • The outlook for patients with eosinophilic esophagitis is favorable. It is a chronic, relapsing condition, but not usually one that is life-threatening. Treatments are evolving using different immune modulators to decrease the allergy-like reactions.
  • Achalasia is a progressive, but treatable disorder. Patients must be closely monitored by a gastroenterologist. A small number of individuals with achalasia may develop squamous cell cancer (carcinoma) as a result.

REFERENCES:

American Academy of Allergy, Asthma & Immunology. "Eosinophilic Esophagitis (EoE)."
<http://www.aaaai.org/conditions-and-treatments/related-conditions/eosinophilic-esophagitis;>

Cancer.org. Esophagus Cancer.
<http://www.cancer.org/cancer/esophaguscancer/detailedguide/index>

Devuni, D, MBBS. "Esophagitis." Medscape. Updated: Nov 12, 2015.
<http://emedicine.medscape.com/article/174223-overview>

McDonagh, MS, et al. "Appendix E. Esophagitis grading scales used in randomized controlled trials." Oregon Health & Science University; 2009 May.
<http://www.ncbi.nlm.nih.gov/books/NBK47264/;>

National Institute of Arthritis and Musculoskelatal Skin Diseases. "What Is Behçet's Disease?" Updated: November 2014.
<http://www.niams.nih.gov/health_info/behcets_disease/behcets_disease_ff.asp>

NDDIC. Barrett's Esophagus.
<https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/barretts-esophagus/Pages/overview.asp<

O Castell, D.O., MD. "Medication-induced esophagitis." Medscape. Updated: Aug 2016.
<https://www.uptodate.com/contents/medication-induced-esophagitis;>

Sami, SS, et al. "The Los Angeles Classification of Gastroesophageal Reflux Disease." June 2013. Video Journal and Encyclopedia of GI Endoscopy. June 2013 Volume 1, Issue 1, Pages 103–104
<http://www.sciencedirect.com/science/article/pii/S2212097113700463>

Last Editorial Review: 9/16/2016

Reviewed on 9/16/2016
References
REFERENCES:

American Academy of Allergy, Asthma & Immunology. "Eosinophilic Esophagitis (EoE)."
<http://www.aaaai.org/conditions-and-treatments/related-conditions/eosinophilic-esophagitis;>

Cancer.org. Esophagus Cancer.
<http://www.cancer.org/cancer/esophaguscancer/detailedguide/index>

Devuni, D, MBBS. "Esophagitis." Medscape. Updated: Nov 12, 2015.
<http://emedicine.medscape.com/article/174223-overview>

McDonagh, MS, et al. "Appendix E. Esophagitis grading scales used in randomized controlled trials." Oregon Health & Science University; 2009 May.
<http://www.ncbi.nlm.nih.gov/books/NBK47264/;>

National Institute of Arthritis and Musculoskelatal Skin Diseases. "What Is Behçet's Disease?" Updated: November 2014.
<http://www.niams.nih.gov/health_info/behcets_disease/behcets_disease_ff.asp>

NDDIC. Barrett's Esophagus.
<https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/barretts-esophagus/Pages/overview.asp<

O Castell, D.O., MD. "Medication-induced esophagitis." Medscape. Updated: Aug 2016.
<https://www.uptodate.com/contents/medication-induced-esophagitis;>

Sami, SS, et al. "The Los Angeles Classification of Gastroesophageal Reflux Disease." June 2013. Video Journal and Encyclopedia of GI Endoscopy. June 2013 Volume 1, Issue 1, Pages 103–104
<http://www.sciencedirect.com/science/article/pii/S2212097113700463>

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