Esophagitis

Esophagitis

Pathogenesis. Esophagitis refers to either infection or inflammation of the esophagus. The most common infection is from Candida albicans. When Candida esophagitis occurs, it is almost exclusively in patients who are HIV positive with a CD4 count <200/mm3, usually even

<100/mm3. Diabetes mellitus is the second most common risk for developing Candida esopha- gitis. Much rarer infectious etiologies of esophagitis are herpes simplex, cytomegalovirus, and aphthous ulcers. Medications and the ingestion of caustic substances are associated with the development of esophagitis. Alendronate and other bisphosphonates are most  common.

Clinical Presentation. Candida esophagitis presents with progressive odynophagia. Although the swallowing is painful, food is still able to pass until the disease is extremely advanced. The major difference between the pain of esophagitis and the pain of spastic disorders is that in esophagitis, the pain is only on swallowing, whereas with spastic disorders the pain occurs intermittently without even needing to swallow. Esophagitis pain is simply from the mechanical rubbing of food against an inflamed esophagus as it passes by.

Diagnosis and Treatment. If the patient is HIV positive, the diagnosis is confirmed simply by seeing a response to empiric treatment with fluconazole. If the fluconazole doesn’t work, then endoscopy should be performed.

Because esophagitis can also result from ingestion of medications and caustic substances, the direct effect of contact between the mucosa and the pill causes inflammation rather than infection. As with most other toxin-mediated damage to an organ, the diagnosis is based on the presentation and finding the toxin in the history. The most common pills that cause esophagitis are alendronate, quinine, risedronate, vitamin C, potassium chloride, doxycycline, NSAIDs, and iron sulfate. Pill esophagitis is managed by simply swallowing pills in the upright position and drinking enough water to flush them into the stomach. Consider pill esophagitis in a young patient who is taking medications for acne with the acute onset of odynophagia.