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 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[1]
- Pill-induced 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]
- 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
Eosinophilic Esophagitis
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.[7] 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:
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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