Esophagitis and its causes: Who is "guilty" when acid is found "not guilty"?

Abstract

Esophagitis is mainly a consequence of gastroesophageal reflux disease, one of the most common diseases affecting the upper digestive tract. However the esophageal mucosa can also be targeted by some infectious, systemic or chemical conditions. Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory disease, characterized by eosinophilic infiltration in the mucosa. Esophageal localization of Crohn's disease is not very common, but it should always be considered in patients with inflammatory bowel disease complaining of upper digestive tract symptoms. There are also forms of infectious esophagitis (e.g., Herpes simplex virus or Candida albicans) occurring in patients with a compromised immune system, either because of specific diseases or immunosuppressive therapies. Another kind of damage to esophageal mucosa is due to drug use (including oncologic chemotherapeutic regimens and radiotherapy) or caustic ingestion, usually of alkaline liquids, with colliquative necrosis and destruction of mucosa within a few seconds. Dysphagia is a predominant symptom in EoE, while infectious, drug-induced and caustic damages usually cause chest pain and odynophagia. Endoscopy can be useful for diagnosing esophagitis, although no specific pattern can be identified. In conclusion when a patient refers upper gastrointestinal tract symptoms and the diagnosis of gastro-esophageal reflux disease is not convincing we should always carefully investigate the patient's clinical history to consider possibilities other than the gastric refluxate.

Keywords: Candida; Caustic; Chest pain; Crohn’s disease; Dysphagia; Eosinophilic esophagitis; Esophagitis; Gastroesophageal reflux disease; Herpes simplex virus; Manometry.

Figure 1

Eosinophilic esophagitis. Endoscopic appearance of eosinophilic esophagitis; note the characteristic multiple rings throughout the esophagus resembling the tracheal aspect and described as “trachealization of the esophagus”. This finding is not common in the early stage of the disease, when tissue elasticity is still preserved by the inflammatory damage.

Figure 2

Esophageal Crohn’s disease. Endoscopic finding in a patient with esophageal localization of Crohn’s disease. Note the apthous erosions and the small ulceration similar to those usually present in the lower gastrointestinal tract. The localization at the middle tract of the esophagus, far from the esophago-gastric junction suggests to rule out the possibility of gastroesophageal reflux disease.

Figure 3

Drug-induced esophageal damage. Endoscopic view of a patient with a history of NSAIDS use. In this case two ulcers are visible, located in the middle third of the esophagus. Also in this case, as well as for Crohn’s disease, the proximal localization makes the possibility of gastroesophageal reflux disease unlikely.

Figure 4

Candida esophagitis. Endoscopic appearance in a patient with severe dysphagia under chronic steroid treatment for rheumatoid arthritis. Note the typical multiple yellow plaques interesting the entire tract of the esophageal wall and strictly adherent to the mucosa.

Figure 5

Diagnostic flow-chart proposed in patients with symptoms suggestive of esophagitis (heartburn, dysphagia, chest pain and others). The area above the dotted line includes all the possible manifestations of GERD that remains the most common etiology of symptoms. The less frequent causes are reported below the dotted line. All the possibilities deserve an accurate collection of clinical history to orientate the differential diagnosis. EoE: Eosinophilic esophagitis; NSAIDs: Non-steroidal anti-inflammatory drugs; IBD: Inflammatory bowel disease; GERD: Gastroesophageal reflux disease.