Esophagitis: When Your Esophagus Becomes Inflamed

Types and causes of esophagitis

Reflux esophagitis

Gastroesophageal reflux disease (GERD) is the most common cause. The valve at the bottom of the esophagus relaxes inappropriately, letting acid splash up. Risk factors include obesity, a hiatal hernia, pregnancy, smoking, large or late meals, alcohol, and some medicines. Doctors grade erosive esophagitis on endoscopy using the Los Angeles classification, from A (mild) to D (severe).

Eosinophilic esophagitis

EoE is a chronic allergic condition in which eosinophils, white blood cells involved in allergy, build up in the esophagus. It is linked to food allergens such as milk, wheat, egg and soy, and to environmental allergies, asthma and eczema. It causes food to stick and is a leading cause of food impaction in young adults. In children, it may cause feeding problems, vomiting and poor growth.

Pill esophagitis

Tablets that stick in the esophagus can cause a local burn or ulcer. Common culprits:

• antibiotics, especially doxycycline and tetracycline
• bisphosphonates for osteoporosis, such as alendronate
• NSAIDs such as ibuprofen and aspirin
• potassium chloride tablets
• iron tablets
• vitamin C and some HIV medicines

Infectious esophagitis

Esophageal candidiasis (yeast) is the most common infection, seen in people with HIV, diabetes, cancer treatment, or using steroid inhalers or tablets. Herpes and cytomegalovirus cause painful ulcers in people with weakened immunity.

Symptoms

• heartburn: a burning feeling behind the breastbone
• pain when swallowing (odynophagia)
• difficulty swallowing (dysphagia) or food sticking in the chest
• chest pain, sometimes severe enough to be mistaken for heart pain
• sour taste or regurgitation of food
• nausea, poor appetite or weight loss
• in babies and children: feeding refusal, vomiting and poor weight gain

Diagnosis

• Upper endoscopy (EGD): a thin camera passed through the mouth shows inflammation, erosions, rings, narrowing or white plaques. Biopsies are taken; at least 6 biopsies are recommended when EoE is suspected.
• Biopsy results: EoE is diagnosed when there are 15 or more eosinophils per high-power field, along with symptoms.
• Barium swallow: shows narrowing and how food passes.
• pH monitoring: measures acid exposure when the diagnosis of reflux is unclear.
• Allergy evaluation in EoE.

Treatment

Reflux esophagitis

• Proton pump inhibitors (PPIs), such as omeprazole, taken 30 to 60 minutes before breakfast, typically for 8 weeks. Severe esophagitis often needs long-term maintenance.
• H2 blockers for milder symptoms.
• Lifestyle measures: lose weight if overweight, raise the head of the bed, avoid meals within 3 hours of bedtime, limit alcohol, stop smoking, and identify personal food triggers.
• Surgery (fundoplication) or endoscopic procedures for selected people.

Eosinophilic esophagitis

• PPIs: help a significant proportion of people.
• Swallowed topical steroids: budesonide or fluticasone, swallowed rather than inhaled, coat the esophagus.
• Elimination diets: removing common food triggers, then reintroducing one at a time with repeat endoscopies.
• Dupilumab: a biologic injection approved for EoE.
• Dilation: stretching a narrowed esophagus.

Pill esophagitis

• Stop or change the medicine if possible.
• Take pills upright with a full glass of water and stay upright for at least 30 minutes.
• Short-term acid suppression and soothing agents may help healing.

Infectious esophagitis

• Antifungal medicine for candida.
• Antiviral medicine for herpes or cytomegalovirus.

Complications

• Esophageal stricture: scarring and narrowing, causing food to stick
• Barrett's esophagus: changes in the lining from long-term reflux, which slightly raise the risk of esophageal adenocarcinoma
• Bleeding from ulcers
• Food impaction in EoE
• Perforation: rare, from severe injury or impaction

Healing time

Mild to moderate reflux esophagitis usually heals within 4 to 8 weeks of PPI treatment. Severe esophagitis may take longer and often needs a follow-up endoscopy. Pill esophagitis often heals within a few days to weeks after stopping the drug. EoE is chronic and needs ongoing treatment.

Frequently asked questions

What are the symptoms of esophagitis?

Common symptoms are heartburn, pain when swallowing, difficulty swallowing, food feeling stuck in the chest, chest pain and regurgitation. Children may refuse food, vomit or fail to gain weight. Severe chest pain should be checked to rule out heart problems.

What causes esophagitis?

The most common cause is acid reflux. Others include eosinophilic esophagitis (an allergic condition), pills that lodge in the esophagus, infections such as yeast or herpes in people with weak immunity, radiation therapy and swallowing caustic substances.

How long does it take for esophagitis to heal?

Reflux esophagitis usually heals in 4 to 8 weeks with acid-reducing medicines. Pill esophagitis heals within days to weeks after stopping the medicine. Eosinophilic esophagitis is a long-term condition that needs ongoing treatment to stay controlled.

What foods should I avoid with esophagitis?

For reflux esophagitis, common triggers include fatty and fried foods, chocolate, peppermint, alcohol, coffee, citrus, tomato and spicy foods, but triggers vary. While healing, soft, cool foods are easier to swallow. In eosinophilic esophagitis, avoidance is guided by a supervised elimination diet.

Is esophagitis serious?

Most esophagitis is not dangerous and heals with treatment. Untreated or severe esophagitis can lead to strictures, bleeding and Barrett's esophagus. Seek urgent care for vomiting blood, black stools, food that will not pass or severe chest pain.