Oesophagitis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Oesophagitis refers to inflammation of the oesophageal mucosa, which can result from acid reflux, infections, medications, or allergic reactions.

Aetiology

1. Reflux Oesophagitis:

  • Gastro-oesophageal reflux disease (GORD): the most common cause, where stomach acid damages the oesophageal lining.

2. Infectious Oesophagitis:

  • Candida albicans: common in immunocompromised patients.
  • Herpes simplex virus (HSV): causes vesicular ulcers in the oesophagus.
  • Cytomegalovirus (CMV): typically affects those with HIV or transplant patients.

3. Drug-Induced Oesophagitis:

  • Bisphosphonates: e.g., alendronic acid.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Tetracyclines: commonly causes oesophageal irritation.
  • Potassium chloride tablets.

4. Eosinophilic Oesophagitis:

  • Chronic immune mediated condition triggered by food allergens.
  • Associated with atopic conditions (asthma, allergic rhinitis, eczema).

Pathophysiology

  • Repeated exposure to gastric acid, irritants, or infections leads to inflammation.
  • Ongoing damage can result in ulceration, strictures, or metaplasia (Barrett’s oesophagus).
  • Eosinophilic oesophagitis involves eosinophilic infiltration, leading to chronic inflammation and fibrosis.

Risk factors

  • GORD.
  • Obesity.
  • Smoking and alcohol consumption.
  • Prolonged use of NSAIDs or bisphosphonates.
  • Immunosuppression (HIV, chemotherapy, transplant patients).
  • Atopic diseases (linked to eosinophilic oesophagitis).

Signs and symptoms

  • Odynophagia: painful swallowing, more common in infectious oesophagitis.
  • Dysphagia: difficulty swallowing, especially in eosinophilic oesophagitis.
  • Heartburn: burning sensation in the chest, worse after eating.
  • Regurgitation: acidic or food reflux into the mouth.
  • Chest pain: can mimic cardiac pain.
  • Oral thrush: suggestive of candida oesophagitis.

Investigations

  • Upper gastrointestinal endoscopy (OGD):
    • Visualises mucosal inflammation, erosions, or ulceration.
    • Allows biopsy to diagnose eosinophilic or infectious oesophagitis.
  • Oesophageal biopsy: confirms eosinophilic oesophagitis (eosinophil infiltration).
  • pH monitoring (specialist investigation): assesses acid exposure in reflux-related oesophagitis.
  • Viral and fungal swabs: if infectious oesophagitis is suspected.

Management

1. Lifestyle Modifications (for GORD related oesophagitis):

  • Avoid trigger foods (spicy, acidic, caffeine, alcohol).
  • Weight loss if overweight.
  • Eat smaller meals and avoid eating before bedtime.
  • Elevate the head of the bed to reduce nocturnal reflux.

2. Pharmacological Management:

  • Proton pump inhibitors (PPIs): first line for acid-related oesophagitis (e.g., omeprazole 20 mg OD for 4–8 weeks).
  • H2 receptor antagonists: second line if PPIs not tolerated (e.g., ranitidine 150 mg BD).
  • Antacids: symptomatic relief (e.g., Gaviscon).
  • Antifungals (e.g., fluconazole): if candida oesophagitis is diagnosed.
  • Antivirals (e.g., aciclovir): for herpes simplex virus oesophagitis.
  • Topical corticosteroids (e.g., budesonide suspension): for eosinophilic oesophagitis.

3. Endoscopic or Surgical Management:

  • Dilatation: for strictures due to chronic inflammation.
  • Fundoplication: considered in severe, refractory reflux-related oesophagitis.
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