Esophagitis
Esophagitis is swelling and irritation, called inflammation, of the tissues that line the esophagus. The esophagus is the muscular tube that carries food and drink from the mouth to the stomach.
Esophagitis can cause painful, difficult swallowing. It also can lead to chest pain. Various things can cause esophagitis. Some common causes include stomach acids backing up into the esophagus, infection, medicines taken by mouth and allergies.
Treatment for esophagitis depends on its exact cause and how badly the tissue that lines the esophagus is damaged. Without treatment, esophagitis can damage this lining. The esophagus may start to have trouble moving food and liquid from the mouth to the stomach. Esophagitis also can lead to other serious health issues. These include scarring or narrowing of the esophagus, unhealthy weight loss, and dehydration.
Common symptoms of esophagitis include:
- Trouble swallowing.
- Painful swallowing.
- Swallowed food becoming stuck in the esophagus, also known as food impaction.
- Burning pain in the chest called heartburn. It’s common to feel this pain behind the breastbone while eating.
- Stomach acid that backs up into the esophagus, also called acid reflux.
Babies and some children with esophagitis are too young to explain their discomfort or pain. Their symptoms can include:
- Feeding troubles, such as getting easily upset, arching of the back and not wanting to eat.
- Failure to thrive.
- Chest or belly pain in older children.
When to see a doctor
Most symptoms of esophagitis can be caused by a few different conditions that affect the digestive system. See your healthcare professional if the symptoms:
- Last more than a few days.
- Don’t get better after using medicines called antacids that are available without a prescription.
- Are bad enough to make it hard for you to eat or cause you to lose weight.
- Happen along with flu symptoms such as headache, fever and muscle aches.
Get emergency care if you:
- Have pain in your chest that lasts more than a few minutes.
- Think you have food stuck in your esophagus.
- Have a history of heart disease and feel chest pain.
- Feel pain in your mouth or throat when you eat.
- Have shortness of breath or chest pain that happens soon after eating.
- Vomit large amounts, often have forceful vomiting or have trouble breathing after vomiting.
- Notice that your vomit is yellow or green, looks like coffee grounds, or has blood in it.
Healthcare professionals tend to label esophagitis by the condition that causes it. Sometimes, esophagitis may have more than one cause. Some of the most common types include the following:
Reflux esophagitis
A valve called the lower esophageal sphincter usually keeps stomach acid out of the esophagus. But sometimes this valve doesn’t close properly. Or it opens when it shouldn’t. In some people, the upper part of the stomach bulges through the large muscle that separates the stomach and the chest. This is known as a hiatal hernia. It also can cause stomach acid to back up into the esophagus.
Gastroesophageal reflux disease (GERD) is a condition in which this backflow of acid is a frequent or ongoing problem. GERD can lead to ongoing swelling and tissue damage in the esophagus.
Eosinophilic esophagitis
Eosinophils (e-o-SIN-o-fils) are white blood cells that play a key role in allergic reactions. Eosinophilic esophagitis can happen if lots of these white blood cells build up in the esophagus. This most likely happens in response to a substance that causes an allergy, acid reflux or both.
Certain foods may trigger this type of esophagitis, including:
- Milk.
- Eggs.
- Wheat.
- Soy.
- Peanuts.
- Seafood.
Typical allergy testing often is not able to spot these foods as being triggers.
People with eosinophilic esophagitis may have other allergies that aren’t caused by food. For example, sometimes allergens in the air, such as pollen, may be the cause. One common symptom of eosinophilic esophagitis is food getting stuck in the esophagus after swallowing. This is called food impaction. Another common symptom is trouble swallowing, also called dysphagia.
Lymphocytic esophagitis
Lymphocytic esophagitis (LE) isn’t a common condition of the esophagus. With LE, a higher than typical number of white blood cells called lymphocytes build up in the lining of the esophagus. LE may be related to eosinophilic esophagitis or to GERD.
Medicine-induced esophagitis
Also called drug-induced esophagitis, this type happens when some medicines taken by mouth cause tissue damage in the esophagus. The damage happens if the medicines stay in contact with the lining of the esophagus for too long. For example, you might swallow a pill with little or no water. If you do that, the pill itself or residue from the pill may stay in the esophagus. Medicines that have been linked to esophagitis include:
- Pain-relieving medicines such as aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve).
- Antibiotics such as tetracycline and doxycycline.
- Medicine called potassium chloride that is used to treat low levels of the mineral potassium.
- Medicines called bisphosphonates that treat bone conditions such as osteoporosis. These medicines include alendronate (Binosto, Fosamax).
- A treatment for heart conditions called quinidine.
Infectious esophagitis
An infection in tissues of the esophagus may cause esophagitis. The infection could be due to bacteria, viruses or funguses. Infectious esophagitis is fairly rare. It happens most often in people with weakened immune systems, such as people with HIV/AIDS or cancer.
A fungus usually present in the mouth called Candida albicans is a common cause of infectious esophagitis. This type of fungal infection often is linked with a weakened immune system, diabetes, cancer, or use of steroid or antibiotic medicines.
Risk factors for esophagitis vary depending on the cause of the condition.
Reflux esophagitis
Factors that raise the risk of gastroesophageal reflux disease (GERD) also are factors in reflux esophagitis. These risk factors include the following:
- Eating right before going to bed.
- Eating meals that are too large and fatty.
- Smoking.
- Gaining extra weight, including from pregnancy.
Foods that can make symptoms of GERD or reflux esophagitis worse include:
- Caffeine.
- Alcohol.
- Fatty foods.
- Chocolate.
- Peppermint.
Eosinophilic esophagitis
Risk factors for this allergy-related esophagitis may include:
- A history of certain allergic reactions. These include asthma, atopic dermatitis and allergic rhinitis, also known as hay fever.
- A family history of eosinophilic esophagitis.
Medicine-induced esophagitis
Risk factors for this type of esophagitis often are linked with issues that prevent quick and complete passage of a pill into the stomach. These factors include:
- Swallowing a pill with little or no water.
- Taking medicines while lying down.
- Taking medicines right before sleep. This risk factor likely is due in part to less saliva being made and less swallowing happening during sleep.
- Being older in age. This may be a factor because of age-related changes to the muscles of the esophagus or to glands making less saliva.
- Taking large or oddly shaped pills.
Infectious esophagitis
Risk factors for infectious esophagitis often relate to medicines such as steroids or antibiotics. People with diabetes also have a higher risk of esophagitis caused by a fungal candida infection in particular.
Other causes of infectious esophagitis may relate to poor immune system function. This may be due to an immune system condition, such as HIV/AIDS, or certain cancers. Also, certain cancer treatments may raise the risk of infectious esophagitis. So might medicines called immunosuppressants that block immune system reactions to transplanted organs.
Without treatment, esophagitis can lead to changes in the structure of the esophagus. Complications can include:
- Scarring or narrowing of the esophagus, known as a stricture.
- Tearing of the lining of the esophagus. This can be due to retching or to healthcare professionals passing medical tools through an inflamed esophagus during endoscopy. Endoscopy is a way for healthcare professionals to check the digestive system.
- A condition called Barrett esophagus in which the cells lining the esophagus are damaged from acid reflux. This raises the risk of cancer that starts in the esophagus, also called esophageal cancer.
Diagnosis involves the steps that your healthcare professional takes to find out if you have esophagitis. Your main healthcare professional or a specialist asks you about your symptoms and gives you a physical exam. You also may need one or more tests. These tests may include the following:
Endoscopy
Endoscopy is a test that’s used to check the digestive system. A healthcare professional guides a long, thin tube equipped with a tiny camera down the throat and into the esophagus. This tool is called an endoscope. Your healthcare professional can use an endoscope to see if the esophagus looks different than usual. Small tissue samples may be taken for testing. This is called a biopsy. The esophagus may look different depending on the cause of the swelling, such as medicine-induced or reflux esophagitis. Before this test, you receive medicine that helps you relax.
Esophageal capsule
This test can be done in the healthcare professional’s office. It involves swallowing a capsule attached to a string. The capsule dissolves in the stomach and releases a sponge. The healthcare professional pulls the sponge out of the mouth with the string. As the sponge is pulled out, it samples the tissues of the esophagus. This may help your healthcare professional figure out how inflamed your esophagus is without doing an endoscopy.
Barium X-ray
This test involves drinking a solution or taking a pill that contains a compound called barium. Barium coats the lining of the esophagus and the stomach so that they show up on images taken. The images can help healthcare professionals find narrowing of the esophagus and other changes in structure. The images also can help spot a hiatal hernia, tumors or other conditions that may be causing symptoms.
Laboratory tests
Small tissue samples removed during an endoscopic exam are sent to the lab for testing. Depending on the suspected cause of the condition, tests may be used to:
- Diagnose an infection caused by a bacterium, a virus or a fungus.
- Find out if allergy-related white blood cells called eosinophils have built up in the esophagus.
- Spot cells that aren’t regular. Such cells may be clues of esophageal cancer or changes that raise the risk of cancer.
Treatments for esophagitis are intended to lessen symptoms, manage complications and treat the causes of the condition. Treatment methods vary based on the cause of esophagitis.
Reflux esophagitis
Treatment for reflux esophagitis may include:
- Medicines available without a prescription. These include antacids (Maalox, Mylanta, others); medicines called H-2-receptor blockers that lower stomach acid, such as cimetidine (Tagamet HB); and medicines called proton pump inhibitors that block stomach acid and heal the esophagus, such as lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec OTC), among others.
- Prescription medicines. These include prescription-strength H-2-receptor blockers and proton pump inhibitors.
- Surgery. A type of surgery called fundoplication may improve the condition of the esophagus if other treatments don’t work. The surgeon wraps a portion of the stomach around the valve that separates the esophagus and stomach. This valve is called the lower esophageal sphincter. This surgery can strengthen the sphincter and prevent acid from backing up into the esophagus.
Eosinophilic esophagitis
Treatment for eosinophilic esophagitis involves staying away from the allergen that trigger symptoms. Treatment also involves easing the allergic reaction with medicines. Medicines may include:
- Proton pump inhibitors. Your healthcare professional likely will first prescribe a proton pump inhibitor. You might take one such as esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec) or pantoprazole (Protonix).
Steroids. Some studies show that swallowed steroids may act on the surface tissue of the esophagus to treat eosinophilic esophagitis. One steroid called budesonide (Eohilia) comes in a liquid form. Another steroid called fluticasone is sprayed into the mouth and then swallowed.
Your healthcare professional can tell you how to swallow the steroid solution so that it coats your esophagus. Swallowing a steroid solution is much less likely to cause serious side effects compared with taking steroid pills by mouth.
Elimination and elemental diets. A reaction to a food allergen is likely the cause of eosinophilic esophagitis. So it may help to stop eating the food that seems to cause the allergy.
Standard allergy tests can’t tell you for sure if you’re allergic to a certain food. For that reason, your healthcare professional may recommend that you remove common food allergens from your diet. Then you can slowly add foods back into your diet and note when symptoms come back. This is known as an elimination diet. It needs to be done with guidance from your healthcare professional.
A more restrictive method is to remove all food from your diet for a time. Your healthcare professional replaces food with an amino acid-based formula. Over time, you slowly get back to eating food. This is called an elemental diet. It also must be done under the watch of a healthcare professional.
- Monoclonal antibodies. This type of medicine works to block the action of certain proteins in the body that cause inflammation. A monoclonal antibody called dupilumab (Dupixent) may be a treatment option for people age 12 and older with eosinophilic esophagitis. Dupilumab is given as an injection every week or every two weeks depending on your weight.
Medicine-induced esophagitis
Treatment for medicine-induced esophagitis involves not using the problem medicine when possible. It also involves lowering the risk of this condition with proper pill-taking habits. Your healthcare professional may recommend:
- Taking a different medicine that is less likely to cause medicine-induced esophagitis.
- Taking a liquid version of a medicine if possible.
- Sitting or standing for at least 30 minutes after taking a pill.
- Drinking an entire glass of water with a pill. But this option isn’t right for everyone. For instance, some people need to drink less fluid because of another condition, such as kidney disease.
Infectious esophagitis
Your healthcare professional may prescribe medicine to treat an infection that causes infectious esophagitis. Medicines can help clear up infections from viruses, bacteria or fungi.
Treating common complications
A doctor called a gastroenterologist who treats digestive conditions may use medical tools to expand the esophagus. This treatment is called esophageal dilation. It tends to be used only if the esophagus becomes very narrow or if food becomes stuck in the esophagus.
During esophageal dilation, your healthcare professional guides small narrow tubes through the esophagus. Versions of these devices may be equipped with:
- A tapered tip that starts with a rounded point that gradually widens.
- A balloon that can be expanded after it’s placed in the esophagus.
References
- Bennett JE, et al. Esophagitis. In: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 9th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed June 5, 2024.
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- Muir A, et al. Eosinophilic esophagitis: A review. JAMA. 2021; doi:10.1001/jama.2021.14920.
- Acid reflux (GER & GERD) in adults. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults. Accessed June 5, 2024.
- Eosinophilic esophagitis. American Partnership for Eosinophilic Disorders. https://apfed.org/about-ead/egids/eoe/. Accessed June 5, 2024.
- Pittman ME. Lymphocytic esophagitis: Current understanding and controversy. The American Journal of Surgical Pathology. 2022; doi:10.1097/PAS.0000000000001667.
- Aceves SS, et al. Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference. Gastrointestinal Endoscopy. 2022; doi:10.1016/j.gie.2022.05.013.
- Medical review (expert opinion). Mayo Clinic. Aug. 1, 2024.
- Kahrilas PJ. Pill esophagitis. https://www.uptodate.com/contents/search. Accessed June 5, 2024.
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- Winter HS. Management of gastroesophageal reflux disease in children and adolescents. https://www.uptodate.com/contents/search. Accessed June 5, 2024.
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