Esophagitis

Esophagitis or inflamed esophagus symptoms include hoarseness, mouth sores, and bad breath.

Esophagitis describes inflammation of the esophagus, which is the tube that connects the throat to the stomach. There are several types of esophagitis depending on the cause. Esophagitis can be caused by infection, irritation of the esophagus, or inflammation of the lining of the esophagus.

There are several types of esophagitis, including the following:

• Reflux esophagitis is caused by a reflux of stomach acid into the esophagus. This can lead to erosive esophagitis.
• Infectious esophagitis is caused by bacteria, viruses, or fungi.
• Barrett's esophagus results from untreated inflammation of the esophagus that can cause changes in the type of cells that make up the inner lining (mucosa) of the esophagus. Barrett's esophagus increases the risk for esophageal cancer.
• Eosinophilic esophagitis is inflammation of the esophagus due to an increase in the number of a type of white blood cells (eosinophils) in the lining of the esophageal wall. It is considered an allergic/immune condition. This leads to dysmotility of the esophagus (the muscles do not work properly to move food through) and difficulty in swallowing. Causes of eosinophilic esophagitis include food allergies, gastroesophageal reflux disease (GERD), parasitic diseases, or inflammatory bowel diseases.
• Behçet's syndrome (also called Behçet's disease) is a form of vasculitis that can cause ulcers in the mouth, esophagus, and other parts of the body. This disease is rare in the U.S.
• Graft-versus-host disease is a complication that can occur after a transplant (usually bone marrow transplant) when the newly transplanted cells attack the recipient's body. Esophagitis may occur in this condition.
• Cancer esophagitis may be a symptom of cancer of the esophagus, or metastatic cancer (cancer that started in another part of the body and then spreads to the esophagus).

Esophagitis can be caused by infection or irritation of the esophagus.

Infections of the esophagus can be caused by bacteria, viruses, or fungi, including:

• Candida, a yeast infection. This is more common in patients with weakened immune systems, such as those with diabetes, HIV/AIDS, patients undergoing chemotherapy, or people who are taking antibiotics or steroids.
• Herpes is a viral infection. It may develop in the esophagus when the body's immune system is weak.

One of the main causes of esophageal irritation is the reflux of stomach acid. There are several causes of reflux:

• GERD (gastroesophageal reflux disease): weakness or dysfunction of the muscle that keeps the stomach closed (lower esophageal sphincter) can allow stomach acid to leak into the esophagus (acid reflux), irritating the inner lining. Also called GERD esophagitis - in severe cases, it can become erosive esophagitis (this also may be referred to as ulcerative esophagitis).
• Vomiting: when vomiting is frequent or chronic it can lead to acid damage to the esophagus. Excessive or forceful vomiting may cause small tears in the inner lining of the esophagus (a rare condition called Mallory-Weiss syndrome [MWS]), leading to further damage.
• Hiatal hernia: This abnormality occurs when a part of the stomach moves above the diaphragm producing a small abnormal pouch, or hiatal hernia, which can lead to excess acid refluxing into the esophagus.
• Achalasia: This is a disorder where the lower end of the esophagus does not open normally, and as a result, food can get stuck in the esophagus or is regurgitated. People with achalasia have a higher-than-normal risk of esophageal cancer.

Medical treatments for other problems can also cause esophageal irritation.

Surgery, including certain types of bariatric (weight loss) surgery, can lead to an increased risk of esophagitis. Medications such as aspirin and other anti-inflammatory drugs can irritate the lining of the esophagus, and cause increased acid production in the stomach which can lead to acid reflux.

Drug-induced esophagitis occurs when large pills are taken with too little water or just before bedtime and they dissolve and get stuck in the esophagus, irritating. Radiation to the chest (thorax), for cancer treatment, can cause burns leading to scarring and inflammation of the esophagus.

Other causes of esophageal irritation:

• Swallowing of foreign material or toxic substances
• Diets high in acidic foods or excessive caffeine
• Smoking

Symptoms of esophagitis include the following:

• Bad breath (halitosis)
• A feeling of food getting stuck while swallowing
• Difficult and/or painful swallowing
• Pain in the middle of the chest, often radiating to the back, is usually associated with swallowing or occurring soon after a meal.
• An unpleasant taste in the mouth
• Indigestion
• Heartburn
• Acid reflux
• Sore throat
• Hoarseness
• Cough
• Mouth sores
• Nausea
• Vomiting
• Abdominal pain or indigestion

A primary care provider (PCP) such as a family medicine specialist, an internist, or a child's pediatrician, may initially diagnose esophagitis. If you need further treatment you will likely be referred to a gastroenterologist, a specialist in disorders of the digestive system.

A gastroenterologist may order specialized tests to look for the cause and extent of the esophagitis. These tests include:

• Esophagogastroduodenoscopy (EGD): An endoscope is used to directly examine the esophagus, stomach, and first part of the intestines. In addition, tissue samples can be obtained (biopsy) to assess the severity of the damage to the esophagus.
• Esophageal manometry: This test is used to measure the pressure inside the lower part of the esophagus. A thin, pressure-sensitive tube is passed through the mouth or nose and into the stomach, which is then pulled slowly back into the esophagus. Patients are asked to swallow, and the pressure of the muscle contractions is measured along several sections of the tube.
• Upper GI series or barium swallow is a test where X-rays are taken of the esophagus after drinking a barium solution. Barium coats the lining of the esophagus and appears white on an X-ray which can show the location and extent of damage to the esophagus.

There are several grading systems used to evaluate the severity of the disease. The Los Angeles Classification System is the most commonly used.

Los Angeles Classification System grades reflux esophagitis:

• Grade A: One (or more) mucosal break no longer than 5 mm that does not extend between the tops of two mucosal folds
• Grade B: One (or more) mucosal break more than 5 mm long that does not extend between the tops of two mucosal folds
• Grade C: One (or more) mucosal break that is continuous between the tops of two or more mucosal folds but which involves less than 75% of the circumference
• Grade D: One (or more) mucosal break which involves at least 75% of the esophageal circumference

In the past, the Savary-Miller Classification System was more widely used but the Los Angeles Classification System is considered more thorough.

Many over-the-counter medications can help neutralize stomach acid and provide short-term relief for the pain of esophagitis caused by acid reflux. Do not take these medications long-term. See a doctor if symptoms persist for more than two weeks.

Pain medications and medications that decrease inflammation such as corticosteroids can be used as adjuncts in the treatment of any inflammatory cause of esophagitis.

Treatment for esophagitis depends on its cause.

• Esophagitis is caused by an infection it is treated with medications to cure the infection.
• Esophagitis is caused by acid reflux or GERD, the condition is treated with medications to reduce or block acid production, for example, heartburn drugs such as H2 blockers or proton pump inhibitors (PPIs).
• Esophagitis due to a medical procedure may need to take acid-blocking medications for a long time.
• Esophagitis due to taking medications may need changes in his/her medications. Consult your doctor before stopping or changing your medications.

If esophagitis is diagnosed early enough, medications and dietary or lifestyle changes are often enough to allow the body to heal. If the damage is severe or leads to scar tissue, which causes difficulty swallowing, more invasive treatments may be necessary.

• Endoscopy can be used to remove any lodged pill fragments, food, or foreign bodies stuck in the esophagus. Stretching (dilatation) of the esophagus can also be done as part of the endoscopy procedure.
• Surgery may be necessary to remove any damaged portions of the esophagus. In the case of Barrett's esophagus, where the risk of cancer is increased, surgery might be the treatment of choice.
• Eosinophilic esophagitis is treated with gentle stretching of the esophagus (dilatation) and medications to decrease white blood cells (eosinophils) in the lining of the esophagus.
• Achalasia may be treated with stretching of the esophagus (dilatation) when oral medications fail to improve symptoms.

Diet is often key to reducing the symptoms of esophagitis. The GERD diet is aimed at reducing acid reflux, the main cause of esophagitis.

Foods that soothe esophagitis symptoms

• Eat low-fat, high-protein meals
• Eat smaller meals, more frequently
• Eat soft foods that are easily digested

Foods and drinks that aggravate esophagitis symptoms

• Avoid fatty foods
• Avoid spicy foods
• Avoid acidic foods and beverages such as citrus and tomatoes
• Avoid foods that may trigger or worsen heartburn including chocolate, mint, onions, or garlic
• Stop eating before you feel full
• Avoid coffee or tea (even decaffeinated), alcohol, and soda

Lifestyle changes that may alleviate symptoms of GERD and esophagitis include:

• Stop smoking
• Remain upright while eating and for about 2-3 hours afterward
• Take small bites and chew food slowly
• Avoid eating within 3 hours of bedtime or laying down
• Raise the head of the bed by 4 to 6 inches (put blocks or a foam wedge under the head of the bed)
• Lose weight
• Wear loose clothing
• Avoid aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve)

The prognosis for esophagitis often depends on the underlying cause.

• Esophagitis caused by infection or inflammation is generally treatable with medications, diet or behavioral changes, and in some cases, surgery. Most people can recover fully, while some have chronic inflammation that is managed with long-term medical treatment.
• Esophagitis caused by reflux, while often manageable, can recur frequently. Many people with reflux require medication or other treatments to prevent relapses.
• A significant percentage of people with GERD go on to develop Barrett's esophagus. Very few patients with Barrett's esophagus develop cancer. A gastroenterologist should monitor those who have Barrett's esophagus.
• The outlook for people with eosinophilic esophagitis is favorable. It is a chronic, relapsing condition, but not usually one that is life-threatening. Treatments are evolving using different immune modulators to decrease allergy-like reactions.
• Achalasia is a progressive, but treatable disorder. A gastroenterologist must monitor patients closely. A small number of individuals with achalasia may develop squamous cell cancer (carcinoma) as a result.

If untreated, esophagitis caused by GERD can lead to bleeding, ulcers, and chronic scarring. This scarring can narrow the esophagus, eventually interfering with the ability to swallow.

A major complication that occurs in a significant portion of people with chronic or longstanding GERD, is Barrett's esophagus, which increases the risk of esophageal cancer. Very few of those who develop Barrett's esophagus will develop esophageal adenocarcinoma.

Severe esophagitis may lead to difficult or painful swallowing and malnutrition.

Some types of esophagitis can be prevented.

• Esophagitis caused by GERD may be prevented by changes in lifestyle and diet.
• Proper oral hygiene can aid in the prevention of esophagitis caused by Candida yeast.
• Take all pills with plenty of water, and in an upright position.