Esofagite

Descrição Geral

• Esophagitis: inflammation of or injury to the esophageal mucosa
• Major etiologies:
  • Medication-induced/pill-induced esophagitis
  • Infectious esophagitis
  • Eosinophilic esophagitis
  • Corrosive esophagitis
  • Reflux esophagitis
• Diagnosis is done by upper endoscopy; findings vary per etiology.

Mnemónica

Para lembrar as causas mais comuns de esofagite: “PIECE”

• Pill-induced esophagitis
• Infectious esophagitis
• Eosinophilic esophagitis
• Corrosive esophagitis
• Etc. (reflux esophagitis)

Medication-induced Esophagitis

Etiologia

• Antibiotics: tetracyclines, doxycycline, clindamycin
• Anti-inflammatories: Nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin
• Bisphosphonates: alendronate, risedronate
• Others: potassium chloride, quinidine, iron supplements, ascorbic acid

Fisiopatologia

• Prolonged, direct contact between the medication(s) and the mucosa causes irritation, erosions, and ulcerations
• Frequently affects site(s) of anatomical narrowing (mid-esophagus, near level of the aortic arch)
• Mechanisms:
  • Disruption of the normal protective mucosal barrier: aspirin, NSAIDs
  • Local caustic damage (e.g., doxycycline is acidic once dissolved)
  • Hyperosmotic solutions contribute to tissue and vascular injury (e.g., potassium chloride).

Fatores de risco

• Occurs more often in elderly patients
• Position of patient (supine > upright)
• Size of medication (delayed transit with large tablets)
• Amount of fluid ingested with medication (intake of at least > 100 mL advised)

Apresentação clínica

• Heartburn
• Retrosternal pain
• Odynophagia, dysphagia

Diagnóstico

• Clinical diagnosis based on history
• Upper endoscopy:
  • Perform if with severe or persistent symptoms (despite discontinuation of the offending medication) 
  • Findings: discrete ulcer, with normal bordering mucosa

Prevenção e tratamento

• Avoid the medication. 
• Resolution expected in < 2 weeks after discontinuation.
• If medication is necessary, take the medication with enough water and maintain an upright position for at least 30 minutes. 

Infectious Esophagitis: Cytomegalovirus (CMV)

Etiologia

• Past CMV infection + CD4 cell count < 50 cells/microL → ↑ risk of reactivation → infection of organs such as the esophagus
• Gastrointestinal (GI) disease from CMV is not frequent but is a serious complication of AIDS (acquired immunodeficiency syndrome).

Fatores de risco

• Patients with AIDS (occurrence decreased since availability of antiretroviral therapy)
• Solid-organ and bone marrow transplant recipients
• Patients receiving immunosuppressive therapy and chemotherapy

Apresentação clínica

• Odynophagia with dysphagia
• Nausea, fever, substernal burning pain
• Can have concurrent infection in retina, lung, liver, colon

Diagnóstico

O diagnóstico é feito por endoscopia digestiva alta.

• Linear or longitudinal deep ulcerations, erosions
• Biopsy: cytomegalic cells (with intracytoplasmic or intranuclear inclusions)

Tratamento

• Ganciclovir or foscarnet
• With AIDS: antiretroviral therapy

Infectious Esophagitis: Herpes Simplex Virus (HSV)

Etiologia

• Majority are HSV type 1.
• Can be primary infection or reactivation of HSV

Fatores de risco

• AIDS
• Organ or bone marrow transplant recipients
• Patients on immunosuppressive therapy

Apresentação clínica

• Odynophagia with dysphagia
• Retrosternal chest pain, +/- fever, concurrent oropharyngeal ulcers

Diagnóstico

O diagnóstico é feito por endoscopia digestiva alta.

• Early lesion: vesicles (rarely seen)
• Punched-out ulcers, +/- plaques
• Biopsy: HSV-infected cells with Cowdry type A inclusion bodies
• Viral culture if no treatment response

Tratamento

• Acyclovir
• With HIV/AIDS: antiretroviral therapy

Infectious Esophagitis: Candidiasis

Etiologia

• Candida albicans: most frequently occurring
• Candida glabrata, Candida krusei: less common

Fatores de risco

• Human immunodeficiency virus (HIV) with CD4 cell count < 100 cells/μL
• Hematologic malignancy
• Hematopoietic cell transplant recipient
• Patients under cytotoxic chemotherapy
• Possible in patients on chronic inhaled corticosteroids

Apresentação clínica

• Odynophagia with dysphagia
• May or may not have oral thrush

Diagnóstico

O diagnóstico é feito por endoscopia digestiva alta.

• White pseudomembrane or plaque lesions
• Biopsy: yeasts and hyphae in mucosal cells
• Culture shows Candida

Tratamento

• Candida: oral fluconazole (nystatin for concurrent oral thrush)
• With HIV/AIDS: antiretroviral therapy

Eosinophilic Esophagitis

Etiologia

• Allergic disorder associated with:
  • Antigen sensitization through foods or aeroallergens
  • Eosinophilia and esophageal dysfunction
• Note: Eosinophils are not normally found in the esophagus.

Fatores de risco

• Asthma
• Atopy
• Allergies

Epidemiologia

• Men > women
• Common age of presentation: 20–30 years
• Caucasians are more affected.

Fisiopatologia

• Eosinophils are recruited on exposure to inhaled or congested allergens.
• Eosinophilic infiltration occurs → eosinophils release interleukins → inflammatory response

Apresentação clínica

• Dysphagia (to solid foods)
• Food impaction
• Odynophagia

Diagnóstico

O diagnóstico é feito por endoscopia digestiva alta.

• Mucosal rings in the esophagus
• Biopsy showing eosinophils (> 15/HPF (high-power field)) 
• Other features:
  • Esophageal eosinophilia persists even with proton pump inhibitor (PPI) intake.
  • Normal pH monitoring

Tratamento

• Referral to an allergist for guidance (dietary therapy)
• Avoid known food allergens.
• Medication therapy:
  • Topical glucocorticoids (e.g., swallowed fluticasone)
  • Systemic glucocorticoids if with significant dysphagia, weight loss, dehydration
  • PPI for reflux symptoms

Corrosive Esophagitis

Etiologia

• Alkali:
  • Drain cleaners, household cleaning products, batteries, bleaches
  • Viscous, tasteless, colorless
• Acids:
  • Battery fluid, toilet bowl cleaners, metal-cleaning liquids, anti-rust solutions
  • Unpleasant taste, malodorous

Fatores de risco

• Intentional (suicidality, underlying psychiatric illness)
• Accidental (usually in children)

Fisiopatologia

• Alkali-induced injury:
  • Rapid damage, affecting esophagus more than the stomach
  • Large amounts, however, result in gastric injury.
  • Process: liquefactive necrosis in the esophagus
• Acid-induced injury:
  • Pain on contact with the oropharynx limits the amount ingested.
  • More oropharyngeal and airway damage than with alkali solutions
  • Acid passes down faster, causing more stomach damage.
  • Process: superficial coagulation necrosis in the esophagus

Complicações das lesões graves

• Perforation
• Bleeding
• Mediastinitis
• Obstruction
• Strictures
• Fistulas
• Laryngeal and tracheobronchial damage from aspiration
• Increased risk for squamous cell cancer (SCC) of the esophagus

Apresentação clínica

• Oropharyngeal, retrosternal, or epigastric pain
• Odynophagia and/or dysphagia
• Hypersalivation
• Stridor or wheezing from burning of the larynx
• Dyspnea
• Nausea/vomiting
• Severe retrosternal pain (perforation and mediastinitis)
• Abdominal tenderness and rigidity (perforation and peritonitis)

Diagnóstico

• History: Note type and amount of ingested agent.
• X-rays:
  • Chest: check for pneumomediastinum, aspiration pneumonia, foreign body (e.g., battery)
  • Abdominal: check for pneumoperitoneum, foreign body 
• Computed tomography (CT) scan: checks depth of necrosis and helps assess need for emergency surgery
• Upper endoscopy:
  • Within 24 hours if without contraindications 
  • Contraindicated in hemodynamic instability, gastrointestinal perforation

Classificação da lesão

• 1st-degree injury: superficial mucosa affected; erythema, edema, hemorrhage, with healing expected
• 2nd-degree injury: ulcers, exudates affect up to submucosal layer; scarring and strictures possible
• 3rd-degree injury: transmural in-depth, with deep ulcers and perforation of the wall

Tratamento

• Airway protection; assess need for intubation
• Fluid resuscitation
• NPO (nothing by mouth)
• No nasogastric insertion, no emetics
• PPIs
• Antibiotics for suspected perforation
• Evaluate for surgical indications
• Surveillance: upper endoscopy 15–20 years later to screen for SCC

Esofagite de Refluxo

A esofagite de refluxo é também conhecida como doença de refluxo gastroesofágico (DRGE).

Etiologia e Fisiopatologia

• Retrograde flow of stomach acid into the esophagus due to transient relaxation of the lower esophageal sphincter (LES) 
• Most episodes of relaxation are triggered by gastric distention.
• Some have incompetent LES.
• Toxic substances (gastric acid, pepsin, bile salts) cause damage to the distal esophageal mucosa.

Fatores de risco

• Smoking
• Alcohol consumption
• Obesity
• Hiatal hernia
• Stress
• Scleroderma
• Zollinger-Ellison syndrome causing increased acid secretion

Apresentação clínica

• Retrosternal “heartburn” or pyrosis
  • Worsens when postprandial or lying down
  • May cause awakening from sleep
  • May be exacerbated by emotional stress
• Regurgitation
• Hoarseness
• “Brackish” taste in the mouth
• Globus sensation
• Chronic, non-productive cough

Complicações

• Erosive esophagitis
• Barrett’s esophagus (at risk for adenocarcinoma)
• Esophageal stricture

Diagnóstico

• Clinical (classic signs of heartburn and regurgitation)
• Confirmed with esophageal pH monitoring if:
  • With unsatisfactory treatment
  • With atypical symptoms
  • Antireflux surgery being considered
• Upper endoscopy is performed if with:
  • Dysphagia
  • Unexplained weight loss
  • Anemia or evidence of gastrointestinal bleeding
  • Refractory symptoms
  • New-onset GERD > 60 years
  • Odynophagia
  • High risk for Barrett’s esophagus
  • 1st-degree relative with gastrointestinal cancer

Tratamento

• Lifestyle modification:
  • Weight loss 
  • Elevation of the head of the bed
  • Elimination of dietary triggers
  • Smoking/alcohol cessation
• Medication therapy: PPIs
• Surgical options include fundoplication, which is indicated for refractory symptoms.