Esophagitis

Question 1

Esophagitis

General and types

Answer 1

Inflammation and irritation of the esophageal mucosa secondary to direct mucosal injury, infection, or an inflammatory process
Types:
Reflux esophagitis/GERD
Eosinophilic esophagitis
Infectious esophagitis
Drug-induced esophagitis

Question 2

Gastroesophageal Reflux Disease (GERD)

general

Answer 2

Occurs at the result of incompetence of the lower esophageal sphincter allowing reflux of gastric contents into the esophagus

Generalized loss of sphincter tone
Recurrent inappropriate transient relaxations of the sphincter triggered by gastric distention

Common condition
10-20% of adults
Occurs frequently in infants

Question 3

Answer 3

Left image (normal): The LES, a structure at the gastroesophageal junction, maintains a high-pressure zone between the esophagus and the stomach. This prevents the reflux of gastric contents. The LES relaxes transiently in response to meals.

Right image (GERD): An incompetent LES (lower baseline pressure) and increased frequency of TLESRs are among the factors causing GERD.

Question 4

Answer 4

The esophageal and gastric fundi should be at an acute angle to each other (about 50 degrees, the so-called angle of His) for optimal barrier function
A: Normal anatomy
B: Widening of the esophagogastric angle

Question 5

GERD

RF

Answer 5

Cigarette smoking
Obesity
Hiatal hernia
Foods & Drinks:
Alcoholic and caffeinated beverages
Fried or fatty foods
Citrus or spicy foods
Chocolate
Red sauce
Medications that decrease LES pressure:
Nitrates
Calcium channel blockers

also people who lay down 2-3 hours after eating.

Question 6

GERD

complications (4)

Answer 6

Peptic esophageal ulceration

Esophageal strictures

Barrett esophagus
Replacement of normal squamous epithelium of the distal esophagus with metaplastic columnar epithelium during the healing phase of acute esophagitis

Esophageal adenocarcinoma
Malignancy that often arises from Barrett esophagus

Question 7

GERD

infant clin man

Answer 7

Vomiting
Irritability
Anorexia
Symptoms of chronic aspiration

Question 8

GERD

Adults - typical presentation

Answer 8

Retrosternal heartburn (pyrosis)
30-60 minutes after meals or upon reclining
Regurgitation
Sour or bitter taste in the mouth

Question 9

GERD

Adults - atypical presentation

Answer 9

Dysphagia/odynophagia (esophagitis has developed)
Globus sensation
Hoarseness
Sore throat
Chronic cough
Weight loss

Question 10

GERD Tx

Mild and intermittent symptoms (fewer than two episodes per week) and no evidence of erosive esophagitis/atypical sx

Answer 10

Lifestyle and dietary modification and
As needed, low-dose histamine 2 receptor antagonists (H2RAs)
Famotidine 20 mg BID
Cimetidine 400 mg BID

Question 11

GERD

Dx for Atypical Sx

Answer 11

ENDOSCOPY first to rule out more serious symptoms

Question 12

GERD Tx

Regular, typical symptoms
Empiric and persistent/refractory

Answer 12

Initial diagnostic studies are not warranted

Empiric treatment:
Twice daily H2-blocker or once-daily proton pump inhibitor (PPI) for 8 weeks

Persistent/refractory symptoms:
Maximize PPI dosing for 8 weeks
No improvement with empiric treatment or symptoms of complications…time to refer to GI

Endoscopy with cytologic washings and/or biopsy of abnormal areas

Question 13

Question 14

GERD

Esophagogastroduodenoscopy (EGD)

type of visualization

Answer 14

First-line endoscopic test for patients with alarm symptoms or refractory symptoms

Allows for direct inspection of the esophagus and gastric mucosa for objective evidence of GERD (erosive esophagitis or Barrett esophagus)

• Class A-D grading system for the severity of reflux esophagitis
• Patients with severe erosive esophagitis (Class C and D) on initial endoscopy should undergo a follow-up endoscopy after a two-month course of twice daily PPI therapy to assess healing and rule out Barrett’s esophagus

Class A = mild esophagitis
Class D = severe esophagitis

Evidence of mucosal healing on repeat endoscopy → decrease PPI therapy to once daily

Question 15

GERD

Ambulatory pH monitoring

Answer 15

Allows for detection of gastroesophageal reflux
Used to confirm the diagnosis and check the adequacy of treatment
Performed for 24 or 48 hours
Measures the frequency of thepHdropping below < 4.0

Question 16

Ambulatory pH monitoring

reliable detects (3)

Answer 16

Pathologic acid exposure

Frequency of reflux episodes

Correlationof symptoms with reflux episodes

Question 17

Ambulatory pH monitoring

Indications/Forpatientswith (3)

Answer 17

Extraesophageal symptoms

GERDrefractory to medications

No endoscopic findings

Question 18

GERD

Lifestyle and dietary modification

Answer 18

Elevation of the head of the bed about 6 inches
Encourage weight loss
lay on LEFT side (not R side)
Avoiding the following:
Eating within 3 hours of bedtime
Strong stimulants of acid secretion (coffee, alcohol)
Specific foods (fatty foods, chocolate, red sauces)
Smoking
Medications that decreased LES pressure

IMPLEMENTED FOR ALL PTS

Question 19

GERD

Antacids

Answer 19

Do not treat the disease, but balancespH
Useful in intermittent disease only
Provides relief with five minutes; duration of 30-60 minutes

Examples:calcium carbonate, aluminum hydroxide

Question 20

GERD

H2-blockers

Answer 20

Indicated for mild symptomatic GERD
Can be added at bedtime forpatientson proton-pump inhibitors (PPIs) with nocturnal symptoms

Decreases acidsecretion by competitively blockingH2 receptorsin gastricparietal cells

Examples:famotidine,cimetidine

Question 21

Proton pump inhibitor (PPI)

Answer 21

Block gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the luminal surface of the parietal cell membrane
Heals esophagitis, if present

Only partial response to once-daily dosing → may ↑ to the PPI to twice daily, add a H2-blockers, or add on-demand antacid therapy

May be given long-term at the lowest possible dose to prevent symptoms

Question 22

GERD

Sucralfate

Answer 22

(aluminum sucrose sulfate)

Surface agent
Adheres to the mucosal surface, promotes healing, and protects from peptic injury
Mechanisms of action is not completely understood
Treatment option during pregnancy

Can be used short term along with PPI therapy

Question 22

PPI examples and doses

Answer 22

All are equally effective
Omeprazole 20 mg daily
Pantoprazole 40 mg daily
Esomeprazole 40 mg daily
Lansoprazole 30 mg daily

Question 23

GERD

Surgery options

Answer 23

Endoscopic dilation
Repeated as needed for esophageal strictures

Antireflux surgery
Laparoscopic fundoplication
Gastric fundusis wrapped around the loweresophagus
Indicated for patients with grade C or D esophagitis, large hiatal hernias, and those who cannot tolerate drug therapy

Question 24

# Barrett esophagus general

Answer 24

**Precancer** Precursor to adenocarcinoma of the esophagus Seen in ~15% of patients with GERD Risk factors: Male Age ≥ 50 years Obesity Symptoms ≥ 5 years (untreated or sub-optimal treatment) Endoscopic surveillance for malignant transformation is recommended **every 3-5 years** in nondysplastic disease

Question 25

# Barrett esophagus Endoscopic ablative therapy Indicaron and options (4)

Answer 25

For confirmed low-grade dysplasia Mucosal resection Photodynamic therapy Cryotherapy Laser ablation

Question 26

Question 27

# Eosinophilic Esophagitis (EoE) general

Answer 27

Chronic allergic inflammatory disease characterized by the presence of eosinophils in the esophageal tissue Strong association with allergic conditions - food allergies, environmental allergies, asthma, and atopic dermatitis Common age of presentation: 20-30 years Prevalence is increasing Change in epidemiology Increased awareness and detection

Question 28

# EOE Patho

Answer 28

Type 2 T-helper cell-mediated systemic response to food and environmental allergens Release of cytokines: IL-5, IL-13, IL-4, and exotaxin

Question 29

# EOE Infants & children Clin man

Answer 29

Failure the thrive Vomiting Abdominal pain Reflux Heartburn

Question 30

# EOE Adolescents & Adults Clin man

Answer 30

**Solid food dysphagia** 15% of patients being evaluated for dysphagia with endoscopy are found to have eosinophilic esophagitis Heartburn Chest pain Often centrally located and **may not respond to antacids** Food bolus impaction History of food impaction is present in up to 54% of patients

Question 31

# EOE Dx

Answer 31

Clinicopathologic diagnosis requiring specific symptoms and pathologic changes in the esophageal mucosa: Symptoms related to esophageal dysfunction Eosinophil-predominant inflammation on esophageal **biopsy** (proximal and distal), characteristically consisting of **≥ 15 eosinophils** per high power field (HPF) Exclusion of other causes that may be responsible for or contributing to symptoms **Persistence** of esophageal eosinophilia on repeat biopsy after an adequate trial (8 weeks) of twice-daily PPI therapy **confirms the diagnosis** Elevated serum IgE level in 50-60% of patients | eosinophils should NOT be in esophagus

Question 32

# EOE endoscopy

Answer 32

Variety of morphologic features in the esophagus associated with eosinophilic esophagitis Mucosal fragility Whitish papules (representing eosinophil microabscesses) Linear furrows Stacked circular rings - "**trachealization**" Strictures | do biopsy here.

Question 33

# EOE Barium swallow

Answer 33

**Not** sufficient for the diagnosis of EoE Helps characterize anatomic abnormalities and provide information on the length and diameter of strictures

Question 34

Question 35

# EOE Tx

Answer 35

Chronic condition, so the goal of treatment is to **reduce the inflammatory response** **Inhaled or oral suspension of a corticosteroid for 8 weeks** No formulation of topical glucocorticoids has been approved specifically for eosinophilic esophagitis in the United States fluticasone (Flovent) budesonide (Pulmicort) **Acid suppression** Proton pump inhibitors (PPIs) **Initial treatment for eight weeks** One tablet PO daily (if symptoms fail to improve after four weeks of therapy, increase the dose to one tablet PO twice daily) One tablet PO twice daily | allergy testing is also a good move

Question 36

# EOE Dupilumab (Dupixent)

Answer 36

**BEST for EOE** May 2022 - Only monoclonal antibody FDA approved for patients 12 years and older, weighing at least 40 kg January 2024 – FDA approval to  treat patients with EoE aged 1 year and older, weighing at least 15 kg

Question 37

# EOE Esophageal dilation Dilation goal

Answer 37

Effective for **relieving dysphagia** No effect on underlying inflammation Often reserved for patients who have failed more conservative therapy or who have high-grade strictures Dilation is limited to 3 mm or less per session Dilation goal of **15-18 mm** Potential complications: Deep mucosal tears Esophageal perforation

Question 38

# EOE Elimination diets

Answer 38

Allergy testing to identify foods that cause allergy and therefore should be avoided 6-food elimination: Cereals, milk, eggs, fish/seafood, peanuts, and soy