Esophagitis- Causes And Management

What Is Important?

Corrosive esophagitis;  Infectious esophagitis;  Pill-induced esophagitis;  Eosinophilic esophagitis (IBQs, diagnosis, and mgt).

Eosinophilic Esophagitis 

Manifested in both adults and children as severe eosinophilic inflammation that causes esophageal discomfort. Differential GERD diagnosis. Atopy affects more than two thirds of esophagitis patients.
White men are typically impacted. The majority of patients are in their 30s to 40s.

Causes

• GERD
• CTDs
• Drug hypersensitivity 
• Hypereosinophilic syndromes 
• Chrons 
• Infections 

Clinical Features           

Heartburn is the most typical presentation; dysphasia, or trouble swallowing, is the second most prevalent; recurring food impaction; Schätzki rings; EOE; failure to flourish; and aversion to food

Diagnosis     

Endoscopy (OGD) and Biopsies

At presentation, one-third of the patients may have a normal endoscopy. Trachealization of the esophagus; the feline esophagus, which is referred to as "beautiful se cat esophagus,"

Exudates in Endoscopy

Eosinophilic Abscisic 

Crepe paper mucosa: this fragile tissue resembles crepe paper.
• GERD – Mainly impacts the lower esophagus. Eosinophilia esophagitis has the potential to impact both the proximal and distal portions of the lung. However, the intensity is farther away.
• Distal and proximal distribution and two to four site biopsies are advised by the American College of Gastereontology 2019 saw the most recent one. The American Gastroenterology Association has issued its most recent guideline, which calls for a 5-site biopsy by 2022.

Greater than fifteen high-power eosinophils. GERD: 0 to 7. A higher number of basal layer cells.

Also Read: Gastritis And Its Types

Management Of Eosinophilic Disorder                

1.   Diet 

Therefore, adopt an elemental diet (substitute amino acids for protein in the diet) as the majority of peptides or proteins. Allergies can be triggered by protein. Elimination diets are also beneficial.

Take out items that can trigger allergies, such as cow's milk, eggs, and soy. After doing a skin prick test, get rid of it.

Two kinds of diets that eliminate
1. SFED: Six-food elimination diet; includes soy, peanuts, cow milk, eggs, wheat, and shellfish; also, includes prick test allergy test findings. It's a modified version of SPED.
2. Cow milk is eliminated from the diet via the One Food Elimination Diet (OFED). Patients have demonstrated improvement.

2. Medications

Topical and systematic PPI trials ought to be taken into account.  The ACG and AGA advise against PPI trials.  Combine the PPI trial with a food-elimination diet if the patient is responding to PPI.  Topical steroids: highly advised.  Oral steroids—only when a patient is refractory

Omalizumab, an anti-IgE monoclonal antibody, is not advised for use in the real world according to the most recent guidelines. IL5 monoclonal antibodies, anti-IL3 monoclonal antibodies, and monteluchast/cromolyn sodium/anti-TNF.

Endoscopic Dilation: Endoscopy dilution is necessary because patients develop dysphagia and esophageal strictures.

American Gastroenterology Association/ Joint Task Force 2022 Recommendations 

• PPIs over no treatment 
• Topical glucocorticoid over no treatment 
• Topical steroids over systemic steroids 
• Elemental diets over no diet
• Empirical SFED over no treatment 
• Allergy testing based clinic diet over no treatment 
• Continued topical steroid treatment after initial response over the discontinuation 
• In EOE dysphagia with strictures 
• AGA recommends endoscopic dilatation 

EOE (Practical Implementation) 

Use PPI to treat a patient if they respond to the PPI trial.  Proceed to topical steroids -> eosinophilic dilatation if it remains unresponsive.

Also Read: Management of Inflammatory Bowel Disease (Ulcerative Colitis and Crohn's Disease) 

FDA

Infectious Esophagitis 

1. Immune system impaired by CMV esophagitis; organ transplantation
2. Clinical characteristics: dysphagia and odynophagia
3. Serpiginous ulcers are the diagnosis. Here, the surrounding mucosa may be normal, but only the ulcers are carrying CMV viruses.

4.           Do PCR for CMV

Cytomegalic Cell

• Shows the presence of intra-nuclear basophilic bodies.

• Owl eye appearance noticed 

Candida Esophagitis

Have diabetes or a damaged immune system. Oral candidiasis affects around 75% of patients; endoscopy is not necessary; visible white plagues, either low or extensive; Antifungals are used in treatment.

• 1st is fluconazole
• Treat with Ganciclovir or Valgancyclovir

Hsv Esophagitis

• Multiple small punched-out ulcers

Numerous punctured ulcers resemble a volcano.  Multinuclear large cells, intranuclear inclusion bodies, and biopsy of ulcers from the margin are observed.  There are intranuclear entities present; • The nucleus resembles ground glass;  Acyclovir is the prescribed treatment

Infectious Esophagitis

Pill-induced Esophagitis

• Poor pill-taking habits (lying down after taking pills)
• Medications k/t/c pill esophagitis
  • Doxyl/tetra
  • Quinidine
  • Phenytoin
  • KCL
  • Biphosphonates
  • NSAIDs
  • FeSO₄
• Middle 1/3rd
• Kissing ulcers
• Patients heal in 14 to 21 days

Corrosive Esophagitis

Alkali > Acids .  Corrosive esophageal injury is not ruled out in the absence of mouth injury.  Clinical presentation: burning or soreness in the esophagus and throat following consumption of caustic materials.
• Assessment and administration
• Maintained
• Absence of stomach wash and steroids
• Endoscopy (conducted in less than 48 hours for late endoscopy, and within 24 hours for early endoscopy)
• Nasogastric/rice tubes
• It is best to do the endoscopy as soon as possible; it should take 12 hours.
• Endoscopic ultrasonography aids in determining the likelihood that a stricture may occur.

Zargar Grade

I, II A 

• Observe 24 hours to 48 hours 
• Gradual progression to diet

IIb

• Close monitoring
• OGD guided nasojejunal tube
• NPO 2-3d

IIIa, IIIb

• ICU
• NPO 2-3d
• In-hospital obs for 1 week

Also Read: Recent Studies And Trials In Gastroenterology And Hepatology

Hope you found this blog helpful for your NEET SS Gastroenterology and Hepatobiliary preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.