Esophagitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Treatment of esophagitis should be directed against the specific etiology. The mainstay of therapy for reflux esophagitis includes pharmacologic agents that block gastric acid production. Antimicrobial therapy is indicated in infectious esophagitis. Certain lifestyle changes may help to reduce symptoms.

Medical Therapy

Treatment depends on the specific cause. Reflux disease may require medications to reduce acid. Infections will require antibiotics.

• Medications that block acid production, like heartburn drugs.
• Antibiotics, antifungals, or antivirals to treat an infection.
• Pain medications that can be gargled or swallowed.
• Corticosteroid medication to reduce inflammation.
• Intravenous (by vein) nutrition to allow the esophagus to heal and to reduce the likelihood of malnourishment or dehydration.
• Endoscopy to remove any lodged pill fragments.
• Surgery to remove the damaged part of the esophagus.

While being treated for esophagitis, there are certain steps you can take to help limit discomfort.

• Avoid spicy foods such as those with pepper, chili powder, curry, and nutmeg.
• Avoid hard foods such as nuts, crackers, and raw vegetables.
• Avoid acidic foods and beverages such as tomatoes, oranges, grapefruits and their juices. Instead, try imitation fruit drinks with vitamin C.
• Add more soft foods such as applesauce, cooked cereals, mashed potatoes, custards, puddings, and high protein shakes to your diet.
• Take small bites and chew food thoroughly.
• If swallowing becomes increasingly difficult, try tilting your head upward so the food flows to the back of the throat before swallowing.
• Drink liquids through a straw to make swallowing easier.
• Avoid alcohol and tobacco.

Antimicrobial Regimens

• 1. Candida

• Preferred regimen: Fluconazole 100–200 mg/day PO/IV for 14-21 days
• Alternative regimen (1): Itraconazole suspension 100–200 mg PO bid
• Alternative regimen (2): Voriconazole 200 mg PaO bid
• Alternative regimen (3): Amphotericin B 0.3–0.7 mg/kg/day IV for 7 days
• Alternative regimen (4): Caspofungin 50 mg/day IV following a 70 mg loading dose
• Alternative regimen (5): Micafungin 150 mg/day IV
• Alternative regimen (6): Anidulafungin 50 mg/day IV following a 100 mg loading dose
• Note: Maintenance therapy with Fluconazole 100–200 mg/day PO in AIDS patients

• 2. Herpes simplex virus

• 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

• 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

• 4. Aphthous ulceration in immunocompromised hosts

• Preferred regimen: Prednisone 40 mg/day PO for 14 days, tapered over 4–8 weeks
• Alternative regimen: Thalidomide 200 mg/day PO

Eosinophilic Esophagitis

Main article: Eosinophilic esophagitis medical therapy

The optimal treatment of eosinophilic esophagitis remains uncertain. The endpoints of therapy of eosinophilic esophagitis include improvements in clinical symptoms and esophageal eosinophilic inflammation. An eight-week course of therapy with topical corticosteroids (fluticasone 88–440 mcg/day for children or 880–1760 mcg/day for adults or budesonide 1 mg/day for children or 2 mg/day for adults) may be used as the first-line pharmacologic therapy. 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. Evaluation by an allergist for coexisting atopic disorders and food and environmental allergens is advisable. Allergen elimination usually leads to improvement in dysphagia and reduction of eosinophil infiltration. Graduated dilation of esophageal stricture should be performed with caution to minimize the risk of iatrogenic perforation.

Contraindicated Medications

Reflux esophagitis is considered an absolute contraindication to the use of the following medications:

• Dicyclomine