Esophagus - Miscellaneous Conditions

Welcome to Today’s Episode!

In this episode, we explore various esophageal conditions, including infectious esophagitis, pill-induced injury, eosinophilic esophagitis, and more. Tune in for key insights on diagnosis, treatment, and prevention strategies for these disorders.

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Transcript

Welcome back to another episode of AudioBoards! Today, we're diving into some interesting Esophageal conditions.

First, let's talk about infectious esophagitis. It is most commonly seen in immunosuppressed patients—those with AIDS, solid organ transplants, leukemia, lymphoma, and those taking immunosuppressive drugs. The most common pathogens causing this condition include Candida albicans, herpes simplex virus, cytomegalovirus, or CMV. Candida infections can also occur in patients with uncontrolled diabetes or those treated with systemic corticosteroids, radiation therapy, or antibiotics.

Herpes simplex can affect otherwise healthy individuals, typically causing self-limited infection. Symptoms of infective esophagitis include Odynophagia, Dysphagia, Substernal chest pain, and Oral thrush. Oral thrush can also occur in viral infections, making it an unreliable diagnostic sign.

Infections can spread to other sites, like the colon or retina, in CMV esophagitis. Oral ulcers may also occur, particularly in the case of herpes simplex esophagitis.

Treatment for infective esophagitis is often empiric, but endoscopy with biopsy remains the most reliable way to confirm a diagnosis.

Endoscopic findings differ depending on the pathogen:

• Candida appear as yellow-white plaques on the mucosa.
• Shallow, large ulcerations characterize CMV.
• Herpes results in multiple small, deep ulcers.

Treatment for Candida esophagitis typically involves fluconazole, but if symptoms persist, itraconazole or voriconazole can be used. In severe cases, intravenous caspofungin may be necessary. For CMV infections in HIV-positive patients, ganciclovir is the first-line treatment, while foscarnet can be used for those who do not respond to ganciclovir.

Acyclovir or famciclovir is typically sufficient in immunocompetent patients. However, foscarnet may be needed for up to 21 days for those who don't respond.

Next up, let's talk about Pill-Induced Esophagitis. The most frequently implicated drugs include:

• NSAIDs
• Potassium chloride pills
• Antibiotics, like doxycycline, tetracycline, and clindamycin.

This type of esophagitis occurs when medications are swallowed without enough water or while lying down, which increases the risk of injury. Risk factors include decreased salivation, esophageal dysmotility, or the use of large pills, especially when medications are taken while supine.

Symptoms often include retro-sternal chest pain, odynophagia, and Dysphagia, which usually begin several hours after medication ingestion.

For diagnosis, history alone is often enough, but in severe or persistent cases, upper endoscopy is required. Chronic pill-induced esophagitis can result in strictures, hemorrhage, or even perforation.

To prevent damage, it's important to take medications with 4 ounces of water and remain upright for 30 minutes afterward.

Now, let's move on to Eosinophilic Esophagitis, or E.o.E, a disorder in which food or environmental allergens cause inflammation in the esophagus. This condition often leads to strictures and rings. It is most common in men and is typically diagnosed in patients between the ages of 25 and 50. EoE is also strongly associated with other atopic conditions, like asthma, rhinitis, and food allergies.

Patients with EoE commonly experience Dysphagia for solid foods, Food impaction, and Heartburn or chest pain. In children, symptoms may include abdominal pain, vomiting, or failure to thrive.

On testing, patients may show eosinophilia or elevated IgE levels. A barium swallow can reveal a small-caliber esophagus and characteristic focal or tapered strictures. However, the gold standard for diagnosis is endoscopy with esophageal biopsy. The endoscopic findings can include Edema, Concentrated rings or Trachealization of the Esophagus, Exudates, Furrows, and Strictures.

Treatment for EoE focuses on reducing symptoms of inflammation and preventing strictures. This can involve:

• Proton pump inhibitors,
• Topical corticosteroids,
• Food elimination diets, and
• Esophageal dilation for strictures.

For most adults, the first-line therapy is a PPI, taken twice daily for 2 months, followed by repeat endoscopy and biopsy. If symptoms persist, topical steroids like budesonide or fluticasone may be used.

In some cases, esophageal dilation may be needed for patients with strictures or a narrow-caliber esophagus, though it should be done carefully due to the risk of perforation.

Now let's talk about Mallory-Weiss syndrome. This condition is characterized by a nonpenetrating mucosal tear at the gastroesophageal junction. It's typically caused by events that suddenly raise abdominal pressure, such as lifting, retching, or vomiting. Alcohol use disorder is a major predisposing factor. Patients usually present with hematemesis, with or without melena, and often have a history of retching, vomiting, or straining. Diagnosis is confirmed by upper GI endoscopy, where a linear mucosal tear between 0.5 to 4 cm is typically seen at the gastroesophageal junction or just below it in the gastric mucosa.

When it comes to differential diagnosis, we need to consider conditions like peptic ulcer disease, erosive gastritis, arteriovenous malformations, and esophageal varices—especially in patients with underlying portal hypertension, who are at a higher risk for recurrent bleeding. Treatment starts with fluid resuscitation and blood transfusions, and in most cases, bleeding resolves on its own without further intervention. However, for patients with ongoing bleeding, endoscopic hemostatic therapy is required, including options like epinephrine injections, cautery, or mechanical compression of the artery. In refractory cases, angiographic arterial embolization or surgical intervention may be necessary.

Next, let's talk about esophageal webs and Schatzki rings. Esophageal webs are thin, diaphragm-like membranes of squamous mucosa, typically found in the mid or upper esophagus. These can be congenital but are also associated with conditions like eosinophilic esophagitis, graft-versus-host disease, and even iron deficiency anemia, also known as Plummer-Vinson syndrome. Schatzki rings, on the other hand, are smooth, thin mucosal structures located at the distal esophagus near the squamocolumnar junction. These rings are commonly linked to a hiatal hernia and reflux symptoms. While most webs and rings are asymptomatic, those less than 13 mm in diameter can cause solid food dysphagia. The Dysphagia is usually intermittent and not progressive. Larger food boluses, particularly poorly chewed ones, can get stuck, and patients may find relief by drinking extra liquids or after regurgitation.

In some cases, an impacted bolus must be extracted endoscopically. The best way to visualize these lesions is through a barium esophagogram. For symptomatic patients, treatment often involves dilation procedures, such as bougie or balloon dilation or endoscopic electrosurgical incision. However, some patients may require repeat dilations and those with ongoing Heartburn should receive long-term proton pump inhibitors for acid suppression.

Finally, let's discuss the Zenker diverticulum. This is a protrusion of pharyngeal mucosa that occurs at the pharyngoesophageal junction between the inferior pharyngeal constrictor and the cricopharyngeus muscle. The underlying cause is believed to be the loss of elasticity in the upper esophageal sphincter, leading to restricted opening during swallowing. Symptoms typically include Dysphagia, coughing, throat discomfort, and regurgitation. As the diverticulum enlarges, it can retain food, leading to halitosis, spontaneous regurgitation of undigested food, and nocturnal choking. Gurgling in the throat or even a visible neck protrusion may also occur. Complications such as aspiration pneumonia, bronchiectasis, and lung abscess can arise if left untreated. Diagnosis is confirmed through video esophagography. Symptomatic patients usually require a cricopharyngeal myotomy, where the septum between the diverticulum and esophagus is surgically incised. Larger diverticula may require a more invasive procedure called transcervical myotomy with diverticulectomy. However, small, asymptomatic diverticula can often be monitored without intervention.

That's all for today's episode. Thanks for listening to AudioBoards. Stay tuned for more educational content in our next episode! The views and opinions expressed on the AudioBoards Podcast do not necessarily reflect those of our employers. This podcast is for educational purposes only and should not be used to diagnose or treat any medical conditions. It is not a substitute for professional medical advice. Always consult a qualified, board-certified healthcare provider for any medical concerns.