31 Esophageal Disorders
Key Points• Esophagitis is inflammation or infection of the esophagus and can be caused by reflux of gastric contents, infectious organisms, corrosive agents, or direct contact with swallowed pills.
• Candida species, cytomegalovirus, and herpes simplex virus are the most common organisms that infect the esophagus of an immunosuppressed patient.
• The most dangerous esophageal foreign body is a disc (button) battery, which can cause a chemically induced perforation in as little as 4 hours.
• Esophageal perforation may initially be manifested as nonspecific chest symptoms. The condition can rapidly progress to mediastinitis, overwhelming sepsis, and death.
• Esophageal motility disorders represent a heterogeneous group of conditions that result from derangement in peristalsis of the esophagus and abnormal functioning of the lower esophageal sphincter.
Reflux Esophagitis
Epidemiology
Gastroesophageal reflux disease (GERD) describes a constellation of symptoms or complications that result from reflux of gastric contents into the esophagus. Even though approximately 40% of adults in the United States suffer from symptoms of heartburn at least once per month, the overall prevalence of GERD is just 14%.1,2 GERD represents a spectrum of disease from nonerosive to erosive esophagitis and finally Barrett esophagus.3 Common complications of GERD include esophageal strictures and the development of esophageal adenocarcinoma. Within the United States, the incidence of esophageal adenocarcinoma is increasing at an alarming rate of 4% to 10% per year.4
Pathophysiology
A number of conditions and lifestyle choices increase the risk for reflux esophagitis (Box 31.1). The primary pathophysiologic mechanism contributing to the development of GERD is an incompetent lower esophageal sphincter (LES). Inability of the LES to prevent reflux of stomach contents is influenced by esophageal anatomy, impaired gastrointestinal motility, acid hypersecretion, and increased abdominal pressure. Patients with a higher incidence of hiatal hernias, low LES pressure confirmed by manometry, and increased levels of reflux confirmed by esophageal pH monitoring have been shown to experience more severe GERD symptoms.5
Box 31.1 Conditions and Lifestyle Choices that Increase Risk for Reflux Esophagitis
Presenting Signs and Symptoms
Heartburn is more severe when patients are supine, bend forward, wear tight clothing, or consume large meals. The pain may last from minutes to hours and may resolve spontaneously or with antacids. Patients with nocturnal symptoms often complain of “water brash,” which is the bitter, metallic taste of regurgitated gastric contents noted on arising from sleep. Approximately 80% of patients with GERD have primarily nocturnal symptoms that are exacerbated by being supine.6 Patients with daytime symptoms have postprandial heartburn and fullness even when upright. GERD can cause chronic cough, recurrent throat clearing, and wheezing as a result of aspiration of gastric contents from the esophagus into the trachea and larynx.7 A complaint of dysphagia in the setting of GERD is an ominous sign that should prompt endoscopic evaluation for underlying strictures or adenocarcinoma.
Differential Diagnosis and Medical Decision Making
GERD is a clinical diagnosis elicited by a detailed and directed history of the present illness. GERD should be diagnosed only after other life-threatening causes of chest pain have been convincingly excluded (Box 31.2). Providers must consider the potential life threats and serious medical conditions that can be manifested in a similar fashion to GERD. A thorough history is the most important consideration in the differentiation diagnosis of patients with GERD-like symptoms. The initial history should be obtained in concert with immediate electrocardiography. Physical examination, laboratory testing, and radiographic imaging aid only in the exclusion of alternative diagnoses. Cardiac stress testing may be required in certain patient populations. A reported clinical response to antacids should not be used to make the presumptive diagnosis of GERD in the emergency department (ED).
Treatment
Lifestyle modifications may reduce symptoms by decreasing the frequency and amount of gastric reflux. Examples of low-cost, low-risk recommendations are summarized in the Patient Teaching Tips box in this section of the chapter.8
H2RAs have similar efficacy with equivalent dosing schedules (Table 31.1). These agents have previously been recommended as first-line therapy; however, a Cochrane review suggests that PPIs relieve heartburn better than H2RAs do in patients treated without specific diagnostic testing.9 These medications should be used for 2 to 4 weeks before any reassessment of symptoms. Recurrence is a common problem in patients with reflux, and therefore many patients require long-term maintenance therapy.
Table 31.1 Equivalent Dosages for Histamine H2 Receptor Antagonists
| DRUG | RECOMMENDED DOSE |
|---|---|
| Cimetidine | |
| Ranitidine | |
| Famotidine | |
| Nizatidine |
Success rates with PPIs approach 90%, and all agents have equal efficacy at appropriate doses (Table 31.2). Once-daily dosing before breakfast is sufficient for the control of mild to moderate GERD; twice-daily dosing should be considered for those with severe or refractory symptoms. Gastroprokinetic agents (cisapride) and coating agents (sucralfate) are less effective than PPIs but may be useful in selected patients as second-line agents.
Table 31.2 Equivalent Dosages for Proton Pump Inhibitors
| DRUG | RECOMMENDED DOSE |
|---|---|
| Omeprazole | |
| Lansoprazole | |
| Rabeprazole | |
| Pantoprazole | |
| Esomeprazole |
* Second doses should be taken before dinner.
Patient Teaching TipsNext Steps in Care
Further diagnostic evaluation, including endoscopy, pH monitoring, manometry, and referral to a gastroenterologist, may be indicated for patients with persistent symptoms. Patients with known reflux esophagitis should be admitted to the hospital for suspected esophageal perforation, significant bleeding, obstruction, volume depletion, or intractable pain. Emergency upper endoscopy is indicated if life-threatening complications are suspected in patients demonstrating dysphagia, odynophagia, upper gastrointestinal bleeding, or weight loss.10
Infectious Esophagitis
Epidemiology
Infection of the esophageal mucosa, known as infectious esophagitis, may result from a variety of organisms in an immunocompromised host. Esophageal infections are more commonly observed in patients with acquired immunodeficiency syndrome, cancer, neutropenia, or diabetes mellitus or in those taking chronic immunosuppressive medications, especially corticosteroids.11 Candida species are by far the most common cause of infectious esophagitis, although cytomegalovirus (CMV), varicella-zoster virus, and herpes simplex virus (HSV) represent common viral causes of the condition.12
Pathophysiology
Infectious esophagitis results from direct invasion of the infectious agent into esophageal tissue. Immunosuppression from any condition can lead to esophageal infections, although patients infected with advanced human immunodeficiency virus and those with lymphoma and leukemia receiving chemotherapy are at highest risk. Prevention of adherence of esophageal pathogens is an important pathophysiologic defense. Impairment of salivation, impairment of esophageal motility, and reduction in gastric acid production can result in opportunistic infections. Injury to the esophageal mucosa from radiation treatment also increases the risk for infection.12
