What Type of Esophagitis Do I Have?

7 Main Types of Esophagitis

Doctor examining a man.
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Esophagitis is inflammation of your esophagus that can either be caused by infectious or non-infectious reasons. Your esophagus is a muscular tube responsible for carrying food from your throat to your stomach. Because it is located in your upper chest, esophagitis commonly feels like heartburn and is often associated with pain when swallowing. Erosive esophagitis occurs when your esophagus has begun to ulcerate or erode away.

The seven main types of esophagitis include:

  1. acid reflux
  2. infection
  3. caustic ingestion
  4. medication-induced
  5. eosinophilic
  6. chemotherapy and radiation therapy
  7. systemic illnesses

While these seven types of esophagitis comprise the main causes of esophagitis, there are many other less common causes of esophagitis.

Symptoms of Esophagitis

Many of the symptoms related to esophagitis can also be found in other disorders and include:

  • heartburn—may be similar to chest pain in coronary artery disease
  • pain with swallowing (odynophagia)
  • difficulty swallowing (dysphagia)
  • nausea and/or vomiting
  • abdominal pain
  • cough
  • anorexia and weight loss

Based upon your symptoms and medical history, you will probably need one or two different procedures as blood draws will not help differentiate what is causing your symptoms. Depending on your exam, your doctor may start with a barium swallow study, which is also known as an esophagography.

For the barium swallow study, you will go to radiology, where a clinician will take x-rays of your esophagus while you ingest barium with some food. The barium coats your esophagus, which then shows up as white on the x-ray. This will allow your physician to see if you have any obstructions or narrowings in your esophagus.

The barium swallow study is helpful to help determine if your physician needs to consider cancer as a possible cause of your symptoms. If cancer is being considered, a CT scan may also be ordered as a further workup.

The other method, which will sometimes come after a barium swallow study, is an endoscopy, which is used to visualize your throat with a fiber optic scope. An endoscopy, also known as an esophagogastroduodenoscopy (EGD), is performed as an outpatient procedure, meaning that you do not need to be hospitalized overnight. You will, however, be given conscious sedation, so you will need to have someone to drive you home after the procedure. During the endoscopy, the gastroenterologist will look at your esophagus, stomach, and upper intestine. They will look for signs of inflammation or ulceration and look to identify any causes of your symptoms. Biopsies are usually taken to look for any infectious causes for your symptoms.

Reflux Esophagitis

Esophagitis is most commonly caused by gastroesophageal reflux disease (GERD). Most people will experience some reflux of stomach contents. However, you will have an increased risk of developing esophagitis if you experience frequent exposure to stomach acid, pepsin (enzyme in the stomach), and bile, as they can cause inflammation and ulcerations in your esophagus.

If you have esophagitis as a result of reflux disease, you should be treated with a proton pump inhibitor (PPI), like Prilosec or Dexilant, for four to eight weeks. After at least four weeks, your physician will reevaluate your symptoms. If after you have recurrent issues with esophagitis related to GERD or have Barrett's esophagus, you will likely need ongoing PPI therapy.

Infectious Esophagitis

Esophagitis can occur as the result of an infection. If you have a weakened immune system, you will be more susceptible to acquiring an infection that causes esophagitis. This is most often seen in people that have acquired immunodeficiency syndromed (AIDS), an organ transplant, or in people that have had chemotherapy for treatment of cancer.

While you are at an increased risk for esophagitis from infectious causes if you have a weakened immune system, you can still acquire infectious esophagitis with a competent immune system. Infections that commonly causes esophagitis include:

Esophagitis from an infection is generally not able to be distinguished by symptoms or by visualization of the ulcers during an endoscopy. The lesions found during an endoscopy are generally white to yellow in coloration. Candida is often found to be plaque-like, while HSV or CMV is more likely to have ulcers. In order to properly diagnose the infection that is causing esophagitis, your doctor will take "brushings" or biopsies of your esophagus.

If you are diagnosed with a candida infection, then you will be prescribed an anti-fungal medication to treat your esophagitis. If you are diagnosed with a viral infection, like HSV or CMV, then your physician wil prescribe you an antiviral. Prednisone is the treatment of choice if you are diagnosed with apthous esophagitis. Treatment with oral medications will usually last between 14 and 21 days.

Caustic Esophagitis

Caustic esophagitis occurs when you ingest a chemical that burns your esophagus. Acidic products that contain lye, or other acidic compounds, when ingested can cause irritation, ulcers, or perforation (holes or tears) of your esophagus. In children this is usually caused by accidental caustic ingestion. If you suspect your child has ingested a chemical in the home, you can always call Poison Control at (800) 222-1222. If your child is having trouble breathing call 911 immediately.

Harm to your esophagus will be proportional to the amount of time your esophagus was exposed to the chemical. if only a little contact occurred, you may only have some irritation. Further exposure increases your risk for the formation of ulcers or worse damage. Generally, you will need to have an endoscopy to evaluate damage of your esophagus within 24 hours.

If you do not have any adverse symptoms after ingesting a caustic substance, you may only be watched for a few hours. However, if you have symptoms of esophageal damage, you will need to be admitted to the hospital for management.

Medication-Induced Esophagitis

Esophagitis caused by medications is rare. It only occurs in about four out of every 100,000 people. Medication-induced esophagitis can occur by either direct contact, similar to caustic esophagitis, or by affecting protective barriers in the stomach and esophageal lining. Medications that have a low pH (acidic) and can cause medication-induced esophagitis includes:

  • antibiotics—tetracycline, doxycycline, and clindmycin
  • supplements—ascorbic acid (vitamin C) and ferrous sulfate (iron)

Aspirin and nonsteroidal anti-inflamatory drugs (NSAIDs), like Ibuprofen, can disrupt the protect barrier of the esophagus and stomach. This can increase your risk for developing esophagitis. Treatment for any type of medication-induced esophagitis consists of stopping the medication. If you are unable to stop the medication, then your physician will try to order a liquid version of the medication.

In general medication-induced esophagitis will resolve quickly without any long-term effects if the damage is stopped early. Typically you will see improvements as soon as four days.

Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE), is an allergic/immune response. Typically your esophagus does not have any eosinophils, which are white blood cells that are a part of your immune system. If EoE is suspected by your doctor, an endoscopy will be performed by a gastroenterologist. During the endoscopy, biopsies will be taken to look for eosinophils. If eosinophils are found, you will be referred to an allergist for further allergy testing. In order for symptoms to resolve you will need to eliminate exposure to foods that are causing an allergic response in your esophagus. This can be done by:

  • prick skin test—method to test different allergens on your skin
  • blood tests
  • food patch test—method where food is placed in a small aluminum chamber (Finn chamber) and left in contact for 48 hours

In some cases, you may be able to identify the instigating foods to avoid from the testing above. However this may not always identify all the foods you should avoid. In this case, your doctor may recommend a food elimination diet, which removes common foods from your diet. Once symptoms resolve, you can then begin to systematically reintroduce foods into your diet until you have an exacerbation; which then identifies a food you should avoid.

Esophagitis Related to Chemotherapy & Radiation Therapy

Esophagitis can occur as a result of chemotherapy or radiation therapy for treating cancer. Several months may be required for healing, if any, can occur. Treatment of this type of esophagitis will be done using viscous lidocaine to numb your esophagus and sucralfate, which is an antacid to help treat any ulcers. If the chemotherapy or radiation therapy causes permanent strictures, or narrowing of your esophagus, you may need to undergo periodic endoscopies to dilate your esophagus.

Esophagitis Related to Systemic Illness

While your doctor is evaluating your history for causes of your esophagitis, they will consider if you have any systemic illnesses that are prone to developing esophagitis. There are many different types of diseases that may increase your risk of having esophagitis and each has a different method to treat. While corticosteroids, like Prednisone, are commonly used for treatment, you should always discuss the best treatment method with your physician. Different disease that may cause esophagitis include:

Sources:

Approach to the evaluation of dysphagia in adults. UpToDate website. http://www.uptodate.com. Updated October 26, 2017.

Caustic esophageal injury in children. UpToDate website. http://www.uptodate.com. Updated March 1, 2017. 

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

Esophagitis. Medscape website. https://emedicine.medscape.com/article/174223-overview. Updated April 27, 2017.

Graman, PS. (2015). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Updated Edition, 99, 1248-1252.e2

Medication-induced esophagitis. UpToDate website. http://www.uptodate.com. Updated November 8, 2016. 

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