oesophagitis in adults

Introduction

oesophagitis is one of the most common conditions in adults

Classification of adult oesophagitis

reflux oesophagitis
- the most common subtype of 0esophagitis, is caused by the reflux of gastric contents into the oesophagus
- see gastro-oesophageal reflux
eosinophilic oesophagitis (EoE)
- an immune-mediated disorder characterized by eosinophilic infiltration of the esophageal mucosa, driven by a Th2 inflammatory response to food and environmental allergens.
- it is most common in patrients with asthma or hay fever and is thought to be the cause of approx half of the patients who present with food bolus impaction
- unlike GOR, symptoms tend to present whilst eating rather than many hours later
- see eosinophilic oesophagitis (EoE)
bile reflux oesophagitis
- occurs when duodenal contents, including bile acids and trypsin, reflux into the oesophagus, causing mucosal injury.
- it would appear that the damaging potential of bile acids and trypsin depends on the pH of the refluxate, with more severe injury occurring at acidic pH levels
- often co-exists with gastro-oesophageal reflux
- chronic reflux oesophagitis, particularly when caused by a combination of acid and bile reflux, plays a key role in the development of Barrett's oesophagus
  - there appears to be an annual incidence of oesophageal cancer in patients with Barrett's of approximately 0.12-0.5%, although this seems to increase to 6% in those with high grade dysplasia - risk factors include degree of dysplasia, length of Barrett's mucosa and duration of Barrett's mucosa. Risk is reduced by 90% after successful endoscopic ablation, although ongoing surveillance is advised.
- Treatment involves measures to reduce both acid and bile reflux, such as proton pump inhibitors (PPIs), ursodeoxycholic acid, and surgical interventions like Roux-en-Y gastric bypass in severe cases.
thermal oesophagitis
- thermal injury and inflammation may occur from drinking very hot drinks (≥ 60°C) such as tea and there is a link to risk of oesophageal cancer in chronic drinkers of very hot drinks - risk seems to be 2.2x in those who drink at ≥ 65°C in China and Iran compared to those who don't.
drug-induced oesophagitis
- occurs due to direct mucosal injury from medication
- risk factors include female gender, older age, decreased salivary flow, oesophageal motility disorders, and improper medication administration (e.g. taking pills without water or in supine position)
- common medications which cause this include antibiotics (doxycycline, tetracycline, clindamycin), bisphosphonates (alendronate), NSAIDs, potassium chloride, and chemotherapeutic agents.
caustic oesophagitis
- results from the ingestion of corrosive substances (eg. concentrated bleach, alkalis, acids), leading to direct chemical injury to the oesophageal mucosa
- can occur through accidental or intentional ingestion, or less commonly, through occupational exposure to corrosive fumes
- can also occur due to alkali formation from retained button batteries
- complications include perforation, mediastinitis, tracheo-oesophageal fistula, aorto-oesophageal fistulae, stricture formation, and increased risk of oesophageal carcinoma
radiation oesophagitis
- a common complication of thoracic radiotherapy, particularly in patients undergoing treatment for lung, oesophageal, or head and neck cancers
- oesophageal mucosa is highly radiosensitive, and radiation-induced damage can lead to acute inflammation and ulceration
- symptoms typically develop within 2-3 weeks of initiating radiotherapy and may include odynophagia, dysphagia, and retrosternal pain.
- the acute effects of radiation oesophagitis are usually self-limited, long-term complications such as strictures may require endoscopic dilation or surgical intervention.
Candida oesophagitis
- the most common form of infectious oesophagitis, particularly in immunocompromised individuals
- risk factors include HIV/AIDS, immunosuppressive medications, diabetes mellitus, and broad-spectrum antibiotic use
viral oesophagitis
- most commonly caused by herpes simplex virus (HSV) and cytomegalovirus (CMV), both typically affect immunocompromised patients.
bacterial oesophagitis
- rare but can occur due to pathogens like Staphylococcus, Streptococcus, and gram-negative rods
- it does not appear Helicobacter pylori has a direct infective oesophagitis but may cause chronic hypochlorhydria (eg. chronic gastric atrophy) which may allow bacterial overgrowth and potential colonization of the oesophagus by other pathogens
parasitic oesophagitis
- uncommon, can be caused by:
  - Chagas disease (Trypanosoma cruzi)
    - manifests with dysphagia and oesophageal dilation due to destruction of the myenteric plexus
  - Cryptosporidium can cause self-limited oesophagitis in immunocompetent hosts but may lead to severe ulceration in AIDS patients
achalasia-induced stasis oesophagitis
- retained oesophageal contents can undergo bacterial fermentation, producing lactic acid and causing a chemical oesophagitis
- the stagnant food and saliva can promote the growth of fungal organisms, particularly Candida species, leading to infectious oesophagitis
- prolonged exposure of the oesophageal mucosa to these agents can result in erosions, ulcerations, and even stricture formation.
- see achalasia
pressure injury
- ingested magnets can compress the oesophageal wall causing necrosis, ulceration, etc
lymphocytic oesophagitis
- rare, may be associated with conditions such as Crohn's disease, celiac disease and gastro-oesophageal reflux
Graft-versus-host disease (GVHD) oesophagitis
- mucosal sloughing may occur
oesophageal involvement in systemic diseases
- scleroderma - oesophageal dysmotility and GERD-related oesophagitis
- Behçet's disease - punched-out ulcers
- sarcoidosis - mucosal nodularity or cobblestoning
oesophageal tuberculosis
- rare, mainly in immunocompromised;
- see tuberculosis (TB)