Esophagitis medical therapy: Difference between revisions
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*'''3. Cytomegalovirus (CMV) esophagitis'''<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> | *'''3. Cytomegalovirus (CMV) esophagitis'''<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> | ||
*Cytomegalovirus esophagitis can be seen in few patients with AIDS and cytomegalovirus end organ disease. | |||
*Patients present with symptoms of odynophagia, nausea, mid-epigastric or retrosternal discomfort and fever. | |||
*Endoscopy will reveal ulcers in the distal esophagus and diagnosis is confirmed by the demonstration of characteristic intranuclear inclusion bodies in the endothelial cells of the biopsy specimen. | |||
*Culture of cytomegalovirus from the esophageal biopsy is not sufficient to confirm the diagnosis in the absence of microscopic findings as majority of patients with low CD4 counts have positive culture. | |||
:*Preferred regimen: [[Ganciclovir]] 5 mg/kg IV q12h for 14–21 days | :*Preferred regimen: [[Ganciclovir]] 5 mg/kg IV q12h for 14–21 days | ||
:*Alternative regimen (1): [[Foscarnet]] 90 mg/kg IV q12h for 14–21 days, then [[Foscarnet]] 90–120 mg/kg/day IV for maintenance in AIDS patients | :*Alternative regimen (1): [[Foscarnet]] 90 mg/kg IV q12h for 14–21 days, then [[Foscarnet]] 90–120 mg/kg/day IV for maintenance in AIDS patients | ||
Revision as of 18:55, 11 May 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The mainstay of therapy for reflux esophagitis is acid suppression therapy. Patients with infectious esophagitis are treated with antimicrobial therapy, whereas patients with eosinophilic esophagitis are treated with corticosteroids. Supportive therapy for esophagitis includes proton pump inhibitors, topical pain medications (gargled or swallowed), smoking and alcohol cessation, and endoscopy to remove any lodged pill fragments.
Medical Therapy
Treatment of esophagitis depends on the underlying cause:
- Reflux esophagitis: Acid suppression using proton-pump inhibitors
- Infectious esophagitis: Antibiotics, antifungals, or antivirals depending on organism (see regimens below)
- Eosinophilic esophagitis: Topical/systemic corticosteroids (see below)[1]
- Pill esophagitis: Stop offending drug[2]
- Radiation esophagitis: Sucralfate, promotility agents, and viscous lidocaine[3]
Supportive care measures include:
- Acid suppression using proton-pump inhibitors (recommended in all patients)
- Topical pain medications (gargled or swallowed)
- Decreasing or limiting oral intake, total parenteral nutrition (TPN) may be required for advanced cases to allow the esophagus to heal
- Smoking/Alcohol cessation
- Endoscopy to remove any lodged pill fragments
Antimicrobial Regimens
- 1. Candida esophagitis[4]
- Preferred regimen: Fluconazole 100 mg PO qd for 14–21 days OR Itraconazole solution 200 mg PO qd for 14–21 days
- Alternative regimen (1): Itraconazole tablets 200 mg PO qd for 14–21 days
- Alternative regimen (2): Amphotericin B 0.3–0.7 mg/kg/d IV q24h
- Amphotericin B is reserved for patients who have failed therapy with both fluconazole and itraconazole.
- 2. Herpes simplex virus (HSV) esophagitis[5]
- Preferred regimen (1): Acyclovir 5 mg/kg IV q8h for 7–14 days
- Preferred regimen (2): Acyclovir 400 mg 5 times daily PO for 14–21 days
- Preferred regimen (3): Valacyclovir 1 g PO tid for 14–21 days ± maintenance suppressive therapy may be necessary in AIDS
- Alternative regimen (1): Famciclovir 500 mg bid PO for 14–21 days
- Alternative regimen (2): Foscarnet 90 mg/kg q12h IV for 7–14 days
- 3. Cytomegalovirus (CMV) esophagitis[6]
- Cytomegalovirus esophagitis can be seen in few patients with AIDS and cytomegalovirus end organ disease.
- Patients present with symptoms of odynophagia, nausea, mid-epigastric or retrosternal discomfort and fever.
- Endoscopy will reveal ulcers in the distal esophagus and diagnosis is confirmed by the demonstration of characteristic intranuclear inclusion bodies in the endothelial cells of the biopsy specimen.
- Culture of cytomegalovirus from the esophageal biopsy is not sufficient to confirm the diagnosis in the absence of microscopic findings as majority of patients with low CD4 counts have positive culture.
- Preferred regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days
- Alternative regimen (1): Foscarnet 90 mg/kg IV q12h for 14–21 days, then Foscarnet 90–120 mg/kg/day IV for maintenance in AIDS patients
- Alternative regimen (2): Valganciclovir 900 mg PO bid, then 900 mg PO qd for maintenance in AIDS patients
- Note: Maintenance therapy with Ganciclovir 5 mg/kg/day IV or 6 mg/kg/day IV 5 days per week in AIDS patients.
Corticosteroids
- Corticosteroids are recommended in eosinophilic esophagitis.
- First-line regimens include:
- Fluticasone 88–440 mcg PO qd for children, 880–1760 mcg PO qd for adults
- OR
- Budesonide 1 mg PO qd for children, 2 mg PO qd for adults
- Patients without symptomatic and histologic improvement after topical steroids may benefit from a longer course or higher doses of topical steroids, systemic steroids with prednisone, dietary elimination, or endoscopic dilation.[7]
References
- ↑ Rothenberg ME (2009). "Biology and treatment of eosinophilic esophagitis". Gastroenterology. 137 (4): 1238–49. doi:10.1053/j.gastro.2009.07.007. PMC 4104422. PMID 19596009.
- ↑ Zografos GN, Georgiadou D, Thomas D, Kaltsas G, Digalakis M (2009). "Drug-induced esophagitis". Dis Esophagus. 22 (8): 633–7. doi:10.1111/j.1442-2050.2009.00972.x. PMID 19392845.
- ↑ Berkey FJ (2010). "Managing the adverse effects of radiation therapy". Am Fam Physician. 82 (4): 381–8, 394. PMID 20704169.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Dellon, Evan S.; Gonsalves, Nirmala; Hirano, Ikuo; Furuta, Glenn T.; Liacouras, Chris A.; Katzka, David A.; American College of Gastroenterology (2013-05). "ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE)". The American Journal of Gastroenterology. 108 (5): 679–692, quiz 693. doi:10.1038/ajg.2013.71. ISSN 1572-0241. PMID 23567357. Check date values in:
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