Esophagitis

What Causes Esophagitis?

Esophagitis is inflammation of the esophagus, and several factors can contribute to its development:

• Stomach acid exposure: When acid backs up into the esophagus, it can irritate the lining.

• Delayed stomach emptying: Food and acid stay in the stomach longer, increasing the chance of reflux.

• Weak antireflux defenses: Structural or functional issues (like a loose lower esophageal sphincter) make it easier for acid to flow upward.

• Transient relaxation of the lower esophageal sphincter (LES): Temporary loosening allows acid to escape into the esophagus.

• Poor esophageal clearance: The esophagus may not effectively push acid back down.

• Fragile mucosal lining: A weakened esophageal lining is more prone to damage.

• Visceral hypersensitivity: Heightened sensitivity in the esophagus can amplify symptoms.

• Genetic predisposition: Some individuals may be more prone due to inherited traits.

What Esophagitis Looks Like

Traditionally, esophagitis is diagnosed when damage to the esophageal lining is seen during an endoscopy and confirmed by tissue biopsy. But:

• Microscopic inflammation can exist even if the esophagus looks normal on endoscopy.

• Reflux material isn't just acid—it can include hydrochloric acid (HCl), pepsin, bile, and enzymes from the pancreas and intestines.

• Inflammation can interfere with nerve and muscle function, leading to:

  • Lower LES pressure, making reflux more likely.

  • Reduced esophageal motility, meaning the esophagus doesn’t move food or acid efficiently.

One proposed explanation: inflammation may reduce cholinergic (excitatory) signals and increase inhibitory signals, disrupting normal esophageal movement.

• Specific Causes of Esophagitis:
• GERD
• EOE
• IBD (esp Crohn's)
• Radiation induced
  
• Pill-induced
• Graft v Host Dz
• Infectious esophagitis
• Endoscopy
• Biopsy
  
• Site of Bx should be above the distal 15% of esophagus to avoid confusion with normal variance associated with Z-line
• Bx should contain epithelium, lamina propria, and muscularis mucosae
• Bx should be oriented in perpendicular plane to maximize Dx yield
• 3 main features in histologic Dx of esophagitis (2 of 3 preferable for Dx)
  
1. Hyperplasia of the basal layer >15% of thickness
2. Elongation of stromal papillae into upper 1/3 with vascular ingrowth
3. Presence of inflammatory cells: eosinophils, lymphocytes, and neutrophils
   
• Grading of esophagitis is not often done due despite various grading systems
• correlation between macro and micro poor
• histological esophagitis may exist with normal macroscopic appearance
• GERD
• Bx x 4 recommended: two taken near the Z line and two taken 2cm above the Z-line
• minimal histologic criteria include:
• simulataneous occurance of elongated papillae and basal zone hyperplasia with inflammation (Eosinophils)
• Moderate esophagitis: diagnosed if there is ingrowth of vessels in the papillae and at least one eosinophil is present - There should be no eosinophils in a normal esophageal Bx specimen
• EoE
• AGA concensus recommendations - peak eos count > 15/HPF (x40) is required for Dx
  
• Preferential eosinophilic localization is in the superficial portions of the esophageal epithelium and microabscesses (clusters of 4 or more eosinophils)
• multiple level Bx required for Dx
• R/O GERD (PPI trial or pH study)
• Pill Esophagitis
• acute injury to esophagus caused by medication, pill, or similar agent
• most often occurs when pill ingested at bedtime with inadequate water
• assoc w/ acute discomfort, dysphagia, odynophagia, retrosternal pain
• Endoscopy
• focal lesion often localized to one of the anatomicaly narrow areas of the esophagus (or to a new pathological narrowing )\
• Tx:
• supportive (lacking evidence)
• sucralfate
• antacids
• topical anesthetics
• bland liquid or diet
• offending pill may be restarted after complete resolution of symptoms with education regarding medication administration (with at least 4oz H2O)
• List of most common meds assoc w/ esophageal injury/ esophagitis
• Abx
• clindamycin
• doxycycline
• penacillin
• rifampin
• tetracycline
• Antivirals
• Nelfinavir
• Zalcitabine
• zidovudine
• Bisphosphonates
• Alendronate
• Etidronate
• Pamidronate
• Chemotherapeutics
• Bleomycin
• Cytarabine
• Dactinomycin
• Daunorubicin
• 5-Fluorouracil
• Methotrexate
• Vincristine
• NSAIDs
• Aspirin
• Ibuprofen
• Naproxen
• Others
• Ascorbic acid
• Ferrous Sulfate
• Lansoprazole
• Multivitamins
• KCl
• Quinidine
• Theophylline
  

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