Esophagitis

Esophagitis (uh-sof-uh-JIE-tis) is inflammation that may damage tissues of the esophagus, the muscular tube that delivers food from your mouth to your stomach.

Esophagitis can cause painful, difficult swallowing and chest pain. Causes of esophagitis include stomach acids backing up into the esophagus, infection, oral medications and allergies.

Treatment for esophagitis depends on the underlying cause and the severity of tissue damage. If left untreated, esophagitis can damage the lining of the esophagus and interfere with its normal function, which is to move food and liquid from your mouth to your stomach. Esophagitis can also lead to complications such as scarring or narrowing of the esophagus, and difficulty swallowing.

Symptoms

Common signs and symptoms of esophagitis include:

• Difficult swallowing
• Painful swallowing
• Chest pain, particularly behind the breastbone, that occurs with eating
• Swallowed food becoming stuck in the esophagus (food impaction)
• Heartburn
• Acid regurgitation

In infants and young children, particularly those too young to explain their discomfort or pain, signs of esophagitis may include:

• Feeding difficulties
• Failure to thrive

When to see a doctor

Most signs and symptoms of esophagitis can be caused by a number of different conditions affecting the digestive system. See your doctor if signs or symptoms:

• Last more than a few days
• Don't improve or go away with over-the-counter antacids
• Are severe enough to make eating difficult
• Are accompanied by flu signs and symptoms, such as headache, fever and muscle aches

Get emergency care if you:

• Experience pain in your chest that lasts more than a few minutes
• Suspect you have food lodged in your esophagus
• Have a history of heart disease and experience chest pain
• Experience pain in your mouth or throat when you eat
• Have shortness of breath or chest pain that occurs shortly after eating
• Vomit large amounts, often have forceful vomiting, have trouble breathing after vomiting or have vomit that is yellow or green, looks like coffee grounds, or contains blood

Causes

Esophagitis is generally categorized by the conditions that cause it. In some cases, more than one factor may be causing esophagitis.

Reflux esophagitis

A valve-like structure called the lower esophageal sphincter usually keeps the acidic contents of the stomach out of the esophagus. If this valve opens when it shouldn't or doesn't close properly, the contents of the stomach may back up into the esophagus (gastroesophageal reflux). Gastroesophageal reflux disease (GERD) is a condition in which this backflow of acid is a frequent or ongoing problem. A complication of GERD is chronic inflammation and tissue damage in the esophagus.

Eosinophilic esophagitis

Eosinophils (e-o-SIN-o-fils) are white blood cells that play a key role in allergic reactions. Eosinophilic esophagitis occurs with a high concentration of these white blood cells in the esophagus, most likely in response to an allergy-causing agent (allergen) or acid reflux or both.

In many cases, this type of esophagitis may be triggered by foods such as milk, eggs, wheat, soy, peanuts, beans, rye and beef. However, conventional allergy testing does not reliably identify these culprit foods.

People with eosinophilic esophagitis may have other nonfood allergies. For example, sometimes inhaled allergens, such as pollen, may be the cause.

Lymphocytic esophagitis

Lymphocytic esophagitis (LE) is an uncommon esophageal condition in which there are an increased number of lymphocytes in the lining of the esophagus. LE may be related to eosinophilic esophagitis or to GERD.

Drug-induced esophagitis

Several oral medications may cause tissue damage if they remain in contact with the lining of the esophagus for too long. For example, if you swallow a pill with little or no water, the pill itself or residue from the pill may remain in the esophagus. Drugs that have been linked to esophagitis include:

• Pain-relieving medications, such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve, others)
• Antibiotics, such as tetracycline and doxycycline
• Potassium chloride, which is used to treat potassium deficiency
• Bisphosphonates, including alendronate (Fosamax), a treatment for weak and brittle bones (osteoporosis)
• Quinidine, which is used to treat heart problems

Infectious esophagitis

A bacterial, viral or fungal infection in tissues of the esophagus may cause esophagitis. Infectious esophagitis is relatively rare and occurs most often in people with poor immune system function, such as people with HIV/AIDS or cancer.

A fungus normally present in the mouth called Candida albicans is a common cause of infectious esophagitis. Such infections are often associated with poor immune system function, diabetes, cancer, or the use of steroid or antibiotic medications.

Risk factors

Risk factors for esophagitis vary depending on the different causes of the disorder.

Reflux esophagitis

Factors that increase the risk of gastroesophageal reflux disease (GERD) — and therefore are factors in reflux esophagitis — include the following:

• Eating immediately before going to bed
• Dietary factors such as excess alcohol, caffeine, chocolate and mint-flavored foods
• Excessively large and fatty meals
• Smoking
• Extra weight, including from pregnancy

A number of foods may worsen symptoms of GERD or reflux esophagitis:

• Tomato-based foods
• Citrus fruits
• Caffeine
• Alcohol
• Spicy foods
• Garlic and onions
• Chocolate
• Mint-flavored foods

Eosinophilic esophagitis

Risk factors for eosinophilic esophagitis, or allergy-related esophagitis, may include:

• A history of certain allergic reactions, including allergic rhinitis, asthma and atopic dermatitis
• A family history of eosinophilic esophagitis

Drug-induced esophagitis

Factors that may increase the risk of drug-induced esophagitis are generally related to issues that prevent quick and complete passage of a pill into the stomach. These factors include:

• Swallowing a pill with little or no water
• Taking drugs while lying down
• Taking drugs right before sleep, probably due in part to the production of less saliva and swallowing less during sleep
• Older age, possibly because of age-related changes to the muscles of the esophagus or a decreased production of saliva
• Large or oddly shaped pills

Infectious esophagitis

Risk factors for infectious esophagitis often relate to medications, such as steroids and antibiotics. People with diabetes also are at increased risk of candida esophagitis in particular.

Other causes of infectious esophagitis may relate to poor immune system function. This may be due to an immune disorder, HIV/AIDS or certain cancers. Also, certain cancer treatments and drugs that block immune system reactions to transplanted organs (immunosuppressants) may increase the risk of infectious esophagitis.

Complications

Left untreated, esophagitis can lead to changes in the structure of the esophagus. Possible complications include:

• Scarring or narrowing (stricture) of the esophagus
• Tearing of the esophagus lining tissue from retching (if food gets stuck) or during endoscopy (due to inflammation)
• Barrett's esophagus, characterized by changes to the cells lining the esophagus, increasing your risk of esophageal cancer

Diagnosis

Your doctor or specialist will likely make a diagnosis based on your answers to questions, a physical exam, and one or more tests. These tests may include:

Barium X-ray

For this test, you drink a solution containing a compound called barium or take a pill coated with barium. Barium coats the lining of the esophagus and stomach and makes the organs visible. These images can help identify narrowing of the esophagus, other structural changes, a hiatal hernia, tumors or other abnormalities that could be causing symptoms.

Endoscopy

Doctors guide a long, thin tube equipped with a tiny camera (endoscope) down your throat and into the esophagus. Using this instrument, your doctor can look for any unusual appearance of the esophagus and remove small tissue samples for testing. The esophagus may look different depending on the cause of the inflammation, such as drug-induced or reflux esophagitis. You'll be lightly sedated during this test.

Laboratory tests

Small tissue samples removed (biopsy) during an endoscopic exam are sent to the lab for testing. Depending on the suspected cause of the disorder, tests may be used to:

• Diagnose a bacterial, viral or fungal infection
• Determine the concentration of allergy-related white blood cells (eosinophils)
• Identify abnormal cells that would indicate esophageal cancer or precancerous changes

Treatment

Treatments for esophagitis are intended to lessen symptoms, manage complications and treat underlying causes of the disorder. Treatment strategies vary primarily based on the cause of the disorder.

Reflux esophagitis

Treatment for reflux esophagitis may include:

• Over-the-counter treatments. These include antacids (Maalox, Mylanta, others); medications that reduce acid production, called H-2-receptor blockers, such as cimetidine (Tagamet HB); and medications that block acid production and heal the esophagus, called proton pump inhibitors, such as lansoprazole (Prevacid) and omeprazole (Prilosec).
• Prescription-strength medications. These include H-2-receptor blockers as well as proton pump inhibitors, such as esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec) and pantoprazole (Protonix). You also may be prescribed prokinetics such as bethanechol and metoclopramide (Reglan), which help your stomach empty more quickly.

• Surgery. Fundoplication may be used to improve the condition of the esophagus if other interventions don't work. A portion of the stomach is wrapped around the valve separating the esophagus and stomach (lower esophageal sphincter). This strengthens the sphincter and prevents acid from backing up into the esophagus.

  A newer treatment involves minimally invasive surgery to place a ring of tiny magnetic titanium beads around the junction of the stomach and esophagus. In that position, the ring of beads strengthens the lower esophageal sphincter, preventing acid reflux.

Eosinophilic esophagitis

Treatment for eosinophilic esophagitis is primarily avoiding the allergen and reducing the allergic reaction with medications. Medications may include:

• Proton pump inhibitors. Your doctor will likely first prescribe a proton pump inhibitor, such as esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec) or pantoprazole (Protonix).

• Steroids. Some studies have shown that swallowed steroids such as fluticasone (Flovent) and budesonide (Pulmicort) may act topically in the esophagus and help treat eosinophilic esophagitis. The same steroid medications that are inhaled to manage asthma are swallowed to treat eosinophilic esophagitis.

  Your doctor will instruct you on how to swallow the steroid preparation so that it coats your esophagus. This delivery system of steroids is much less likely to cause serious side effects than taking oral steroid pills.

• Elimination and elemental diets. A response to a food allergen is likely the cause of eosinophilic esophagitis. Therefore, elimination of the culprit food may be an effective treatment strategy.

  However, as no tests are currently available to identify the culprit food, your doctor may recommend that you remove common food allergens from your diet. Under your doctor's direction, you'll gradually add foods back into your diet and note when symptoms return.

  Another, more restrictive, approach is to remove all food from your diet and replace it with an amino acid-based formula.

New biologic therapies are being developed to treat eosinophilic esophagitis and will likely be available within a few years. These medications stimulate your body's immune response to fight infection, inflammation or disease.

Drug-induced esophagitis

Treatment for drug-induced esophagitis is primarily avoiding the problem drug when possible and reducing the risk with better pill-taking habits. Your doctor may recommend:

• Taking an alternative drug that is less likely to cause drug-induced esophagitis
• Taking a liquid version of a medication if possible
• Drinking an entire glass of water with a pill, unless you've been told by your doctor to restrict your fluid intake because of another condition, such as kidney disease
• Sitting or standing for at least 30 minutes after taking a pill

Infectious esophagitis

Your doctor may prescribe a medication to treat a bacterial, viral, fungal or parasitic infection causing infectious esophagitis.

Treating common complications

A gastroenterologist may perform a procedure to expand (dilate) the esophagus. This treatment is generally used only when the narrowing is very severe or food has become lodged in the esophagus.

In esophageal dilation, your doctor uses one or more endoscopic devices — small narrow tubes inserted through the esophagus. Versions of these devices may be equipped with:

• A tapered tip that starts with a rounded point that gradually widens
• A balloon that can be expanded after it's inserted in the esophagus

Lifestyle and home remedies

Depending on the type of esophagitis you have, you may lessen symptoms or avoid recurring problems by following these steps:

• Avoid foods that may increase reflux. Avoid eating excessive amounts of foods that you know worsen your symptoms of gastroesophageal reflux. These may include alcohol, caffeine, chocolate and mint-flavored foods.
• Use good pill-taking habits. Always take a pill with plenty of water. Don't lie down for at least 30 minutes after taking a pill.
• Lose weight. Talk to your doctor about an appropriate diet and exercise routine to help you lose weight and maintain a healthy weight.
• If you smoke, quit. Talk to your doctor if you need help ending a smoking habit.
• Avoid certain medications. Avoid some pain relievers and antibiotics, as well as some other medications, if you have an enlarged left upper heart chamber (atrium) or after heart surgery.
• Avoid stooping or bending, especially soon after eating.
• Avoid lying down after eating. Wait at least three hours after eating to lie down or go to bed.
• Raise the head of your bed. Place wooden blocks under your bed to elevate your head. Aim for an elevation of 6 to 8 inches (15 to 20 centimeters). Raising your head by using only pillows isn't effective.

Alternative medicine

No alternative medicine therapies have been proved to treat esophagitis. Still, some complementary and alternative therapies may provide some relief from heartburn or reflux symptoms when combined with your doctor's care. Talk to your doctor about what alternative treatments may be safe for you. Options may include:

• Herbal remedies. Herbal remedies sometimes used for heartburn or reflux symptoms include licorice, slippery elm, chamomile, marshmallow and others. Herbal remedies can have serious side effects, and they may interfere with medications. Ask your doctor about a safe dosage before beginning any herbal remedy.
• Relaxation therapies. Techniques to calm stress and anxiety may reduce signs and symptoms of heartburn or reflux. Ask your doctor about relaxation techniques, such as progressive muscle relaxation or guided imagery.
• Acupuncture. Acupuncture involves inserting thin needles into specific points on your body. Limited evidence suggests it may help people with regurgitation and heartburn, but major studies have not proved a benefit. Ask your doctor whether acupuncture is safe for you.

Preparing for an appointment

If you're experiencing severe chest pain that lasts more than a few minutes or if you suspect you have food lodged in your esophagus or are unable to swallow, get emergency medical care.

If you have other signs or symptoms of esophagitis, you'll likely start by seeing your primary care doctor. For some diagnostic tests, your doctor may refer you to a specialist in digestive system disorders (gastroenterologist) or an allergy specialist (allergist). Preparing for your appointment with your doctor or a specialist will help you make the best use of your time.

What you can do

Make a list ahead of time that you can share with your doctor. Your list should include:

• Symptoms you're experiencing, including any that may seem unrelated to pain, difficulty swallowing or reflux
• Key personal information, including any major stresses or recent life changes
• Medications that you're taking, including vitamins and other supplements
• Family history of allergies and disorders of the esophagus or stomach
• Questions to ask your doctor

List questions for your doctor from most important to least important in case time runs out. If you think you have signs or symptoms of esophagitis, you may ask some of the following questions.

• What tests will I need to diagnose the condition?
• Do these tests require any special preparation?
• How long will it take to find out the results of tests?
• What treatments are available, and which do you recommend?
• How will we know if the treatment is working?
• Will I need follow-up tests?
• What steps can I take on my own to prevent a recurrence of the symptoms?
• I have other medical conditions. How can I best manage these conditions together?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

• How severe is your pain or discomfort?
• Do you have difficulty swallowing?
• How often do you experience symptoms?
• Does anything seem to prompt or worsen symptoms, such as certain foods?
• Does anything lessen symptoms, such as taking over-the-counter antacids or avoiding certain foods?
• Are symptoms worse at certain times of the day?
• Do your symptoms begin shortly after taking any medications? If so, which medications?
• Do you have any allergies, and do you take any allergy medication?
• Have you ever had food get stuck in your throat after swallowing?
• Do you ever have food come back up after swallowing?
• Do you have a family history of gastrointestinal problems?

What you can do in the meantime

If you know that certain foods trigger or worsen symptoms, avoid them. Common culprits include caffeine-containing drinks, alcohol or spicy foods. Taking over-the-counter antacids may provide short-term relief of symptoms.

If you suspect that your symptoms are related to a prescription medication, don't stop taking the drug without first talking to your doctor. If possible, limit the use of over-the-counter medications that could be causing problems. When you take pills, drink a glass of water and avoid lying down immediately afterward.

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