Infectious & Candida Esophagitis

Infectious Esophagitis

• Most often results from non-infectious conditions like GERD
• Can be caused by impaired immunity, chemotherapy, HIV, transplant, or HIV
• Typically signifies an alteration in immune status, predisposing patients to opportunistic infections
• It is linked to impaired cellular immunity, with a CD4 count of less than 100, hematologic malignancies, cell transplants, cytotoxic chemotherapy, and inhaled corticosteroids

Candida Esophagitis

• Candida esophagitis is marked by pain during swallowing and retrosternal pain
• Symptoms include fever and chills
• White plaques are observed in the oral cavity
• Ulcers in the oropharyngeal region are possible
• Differential diagnoses include HSV, CMV, and GERD, as well as pill esophagitis, NSAIDs, and KCl
• Empiric treatment can be guided by medical history and physical examination
• Endoscopy is recommended if there is no response within 3-4 days
• Treatment usually involves fluconazole with an 80-90% cure rate
• Voriconazole is used for candida krusei or after endoscopy
• Echinocandin antifungals are administered in a hospital setting
• Treatment failure may be attributed to Non-albicans, drug resistance, being immunocompromised, chronic antibiotic use, or uncontrolled diabetes mellitus

HSV Esophagitis

• HSV esophagitis often affects immunocompromised patients
• Type 1 of the herpes simplex virus is a common cause
• Altered cellular immunity and transplant recipients are risk factors
• The epidemiology points to altered cellular immunity and males around age 35
• Symptoms include odynophagia, dysphagia, fever, abdominal pain, anorexia, glossitis, and oropharyngeal ulcers
• Diagnosis is made through endoscopic visualization, revealing ulcerations, and volcano ulcers
• Ground glass nuclei, Cowdry's Type A, and giant cells are observed in biopsies
• Treatment includes acyclovir for immunocompromised patients
• Resolution may occur spontaneously in immunocompetent individuals
• Acyclovir can be used for severe odynophagia or dysphagia
• Alternative treatments are foscarnet and viscous lidocaine
• Antiviral medications may be given for transplant patients
• Low-dose antiviral medication can be used for a history of HSV esophagitis
• Patients with active malignancy on chemotherapy and radiotherapy face a higher mortality risk

Cytomegalovirus (CMV)

• CMV often affects patients with HIV or severe immunosuppression
• Immunocompetent patients is typically subclinical
• Pathophysiology: transmission occurs via saliva, genital secretions, breast milk, and rarely blood products or organ transplants
• Immune System Evasion: involves downregulated MCH class 1 molecules, inhibition of natural T killer cells, and interruption of apoptosis in infected cells
• Viremia: after replication, the virus enters the bloodstream, targeting epithelial cells, particularly in the respiratory, gastrointestinal, and genitourinary systems
• Latency: occurs in myeloid cells (monocytes) following the primary infection
• Reactivation: is linked to weakened or compromised immunity, including HIV, transplants, and immunosuppression
• Epidemiology: is more prevalent in crowded conditions and less common in developed countries
• Presentation (Immunocompetent): causes subclinical or "mono" syndromes, such as fever, pharyngitis, and LAD
• Presentation (Immunocompromised): causes retinitis, pneumonitis, colitis, or esophagitis
• Symptoms: include fever, malaise, fatigue, dysphagia, LAD, and splenomegaly
• Diagnosis relies on CMV titers(PCR). Acute infection shows IGM, IGG negative and acute Reactivation shows IGM, IGG positive
• Other diagnostic tests are serology and histopathology to find the invasive cells

Labs, Imaging, and Endoscopy for CMV

• Labs: CBC shows leukopenia, neutropenia, reactive lymphocytes, and thrombocytopenia. CMP includes increased AST/ALT measurements
• Imaging: a chest X-ray may be conducted during the diagnosis process
• Endoscopy: reveals shallow, "punched out" ulcers in the distal esophagus
• Histopathologic diagnosis is the most accurate method
• Co-infections with HIV are common, especially when CD4 counts are less than 50
• Treatment [HIV]: involves ART Therapy, switching from Ganciclovir to Valganciclovir
• A dilated eye exam is indicated to rule out CMV retinitis, especially during reactivation
• Stem cell transplant patients face a high risk of mortality from pneumonia

CMV Prophylaxis and Complications

• Prophylaxis includes organ recipients and stem cell transplant patients
• Valganciclovir is used, especially
• Complications include edema, strictures, and perforations

Medication Induced Esophagitis

• Preventable
• Can cause mucosal injury and systemic effects like GERD or infection
• Pathophysiology: Prolonged contact of medication on esophageal mucosa damages the mucosa, leading to an intense inflammatory response
• Epidemiology: Self-limited, goes unreported, and typically occurs in the mid-esophagus
• Tends to occur more in women
• Risk Factors: position, size, amount of fluid ingested, night-time meds, and esophageal motility disorders
• Common drugs: Tetracyclines, NSAIDs, and Bisphosphonates
• Can be suspected for patients who swallow pills without water or lie down after medicating
• Symptoms include retrosternal pain, odynophagia, dysphagia, and anxiety
• Endoscopy is recommended after 1 week of persistent symptoms or sooner if the patient shows Hematemesis, abdomen pain, or weight loss

Medication & GERD Treatment

• Treatment includes discontinuation of medication
• A proton pump inhibitor is often included
• Most patients improve without significant intervention

GERD

• GERD develops when stomach contents reflux into the esophagus, causing symptoms and potential long-term complications
• Diagnosis is based on endoscopic appearance
• Non-erosive reflux indicates that the patient is symptomatic without evidence of mucosal injury
• Epidemiology: 10-20% of the western world population, with equal prevalence among men and women, accompanied by heartburn and regurgitation
• Risk Factors: include gastroesophageal junction incompetence, obesity, scleroderma, NSAID use, tobacco and EtOH use, and family history

GERD Signs, Symptoms & Diagnostics

• Symptoms: Heartburn, Regurgitation, Retrosternal bleeding, Dysphagia, Chest pain, Globus sensation, Odynophagia, Cough, hoarseness, wheezing, and hypersalivation
• Patients presenting classic symptoms can be treated based on history alone
• Symptoms that Warrant attention: new onset dyspepsia, GI bleeding, iron deficiency, anorexia, unexplained weight loss, dysphagia/odynophagia, persistent vomiting, or a family history of GI cancers
• Dx: Includes CBC, CMP, LFTs, Cardiac Enzymes, Lipase/Amylase, EKG, CT, Breath test for H. Pylori, Double Contrast Barium Swallow, Upper Endoscopy, Esophageal Manometry, and Ambulatory Esophageal pH

GERD Treatment

• Treatment: involves weight loss, elevating the head of the bed, and avoiding lying down for 2-3 hours after meals, and avoiding caffeine as well as chocolate and spicy foods
• Limiting carbonated beverages and peppermint may assist
• Other treatment methods involve avoiding smoking and EtOH

GERD Treatment Regimens

• Mild/Intermittent symptoms (<2 episodes/week): involve life-style modifications and low-dose histamine 2 antagonists and OTC antacids
• Treatment: Includes Low Dose H2, standard Dose H2, and PPI
• Erosive Esophagitis with frequent/severe symptoms (>2 episodes/week): involves lifestyle modifications and a standard PPI dose daily x 8 weeks
• Improved conditions: require a move to PPI low dose + add H2 and patients can wean meds without severe erosive esophagitis/Barret's
• Additional Treatment: PPI low dose + H2 blocker or PPI standard dose
• Increased H2 blockers or Prilosec may treat symptomatic episodes 4-8 weeks after therapy

GERD Surgical Treatment, Follow Up, & Los Angeles Classification

• Surgical: only for cases with proven GERD, non responsive to medicine, younger patients unwilling to be on lifelong meds, or structurally defective
• Creates a new anti-reflux valve at gastroesophageal junction or enables patient preservation to swallow normally and belch
• Nissen Fundoplication treatment: wraps the fundus of the stomach around the bottom of the esophagus to increase the tone of the LES
• POST-OP: often causes Dysphagia, Gastric bloat, Infection, Bleeding, or Perforation
• Complications Post Op: Barrett's and Esophageal Stricture
• Extra-Esophageal Complications of GERD: Asthma, LPR, Chronic laryngitis, and Laryngeal or Tracheal stenosis
• 2/3 patients with nonerosive reflux will relapse after meds are discontinued
• Erosive GERD can lead to Barrett's Disease development
• Los Angeles Classification is used with Grade A indicating <5mm, Grade B: >5mm, not continuous, Grade C: at least mucosal break, continuous but not circumferential, or Grade D: mucosal break at least ¾ of the luminal circumference of the esophagus

Barrett's Esophagus

• Chronic GERD complication, characterized by intestinal metaplasia inside lower esophagus and greater risk of cancer
• Genetic and environmental predisposition cause cells in lower esophagus structural makeup to change
• 10% of people with symptomatic GERD in population, and 2% of the population are affected, mainly white males that then have an increased risk of adenocarcinoma
• GERD increases the risk of Barrett's by five times
• Risk Factors include obesity, family history, and smoking
• Symptoms: similar to GERD
• Factors for Screening Include: Hiatal hernia, Male, >50, Whites, Central obesity, Smokers, and family history

Diagnosis & Treatment of Barrett's Esophagus

• Methods for Diagnosis: Upper endoscopy done every 3 yrs if >3cm or every 5 years if <3cm, optimize anti-reflux, or another endoscopy after 2 months but no longer than 6
• Treatment for low grade BE: Resection, Ablation, or Surveillance of endoscopy every 6 months for 1 year, then annually
• Treatment for high grade BE is an Esophagectomy
• No significant overall mortality differences exist between people with and without Barrett's

Eosinophilic Esophagitis

• Chronic immune-mediated inflammatory
• Presentation: Esophageal dysfunction, eosinophilic infiltration within esophageal mucosa, and its most common is solid food dysphagia
• Precise mechanism remains elusive, but may be due to swelling and can be caused by allergic conditions
• Urban settings, cold/arid zones, males, need medical attention for 4.5 years
• Risk Factors Include: History of antibiotics, NICU, Acid Suppressive Therapy, non-smokers, breast fed, and no NSAIDs
• Symptoms: Dysphagia, centrally located chest pain, drool, upper abdomen pain, anxious, drooling, non-focal abdomen exam
• Diagnosis via finding greater than 15/hpf eosinophilia-related inflammation in biopsy sample

Esophageal Disorders, Dysphagia Definition, & Phases

• Dysphagia Definition: subjective sensation of abnormality or difficulty swallowing. Acute Dysphagia is where patient cannot swallow solids, liquids, secretions, and any impaction to FB
• Odynophagia: pain with swallowing
• Globus Sensation: A Nonpainful sensation of lump, tightness, FB, retained food bolus pharyngeal or cervical
• Deglutition: the act of swallowing
• Phases of Swallowing:
  1. Buccal: begins when bolus contacts hard palate and tongue retracts, elevates to push bolus off as seals open