Esophagitis medical therapy

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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

Lifestyle Modifications

• The following measures are recommended as the first line to treat GERD:
  • Weight loss
  • Elevating head of the bed
  • No eating two hours before going sleep
• Avoidance of the following foods and lifestyles is recommended in treatment of GERD:
  • Coffee
  • Alcohol
  • Excessive amounts of Vitamin C supplements
  • Foods high in fats
  • Smoking
  • Eating shortly before bedtime
  • Large meals
  • Chocolate and peppermint.
  • Acidic foods, such as oranges and tomatoes.
  • Cruciferous vegetables such as: Onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts
  • Milk and milk-based products

Medical therapy

• The medical therapy is indicated for the patients who have persistent GERD regardless the lifystyle and food modifications.
• The following medical therapies are strongly recommended by the American College of Gastroenterology:
  • Antacids:
    • Preferred regimen (1): Aluminum hydroxide 640 mg 5 to 6 times daily PO after meals and at bed time.
    • Preferred regimen (2): Calcium carbonate One gram PO.
  • Histamine-receptor antagonists (H2RA):
    • Preferred regimen (1): Ranitidine 150 mg q12 daily PO
    • Preferred regimen (2): Cimetidine 400 mg q6h or 800 mg q12 PO for 12 weeks
    • Preferred regimen (3): Famotidine 20 mg q12 PO for 6 weeks
  • Proton pump inhibitors:
    • Preferred regimen (1): Omeprazole 20 mg q24 PO for up to 4 weeks
    • Preferred regimen (2): Esomeprazole 20 mg or 40 mg q24 IV
  • Prokinetic medications:
    • Preferred regimen (1): Metoclopramide 10 mg q24 PO for 4 to 12 weeks

• Infectious esophagitis: Antibiotics, antifungals, or antivirals depending on organism (see regimens below)

Antimicrobial Regimens

• 1. Candida esophagitis

• 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

• 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

Duration of therapy: 21–42 days or until signs and symptoms have resolved

• Preferred Regimen (1): Ganciclovir 5 mg/kg IV q12h, may switch to valganciclovir 900 mg PO q12h once the patient can absorb and tolerate PO therapy.
• Alternate Regimen (1): Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for patients with treatment limiting toxicities to ganciclovir or with ganciclovir resistance OR
• Alternate Regimen (2): Oral valganciclovir may be used if symptoms are not severe enough to interfere with oral absorption OR
• Alternate Regimen (3): For mild cases: If ART can be initiated or optimized without delay, withholding CMV therapy may be considered.
  • Note (1): Maintenance therapy is usually not necessary, but should be considered after relapses.

• Eosinophilic esophagitis: Topical/systemic corticosteroids (see below)
• The medical therapy of the EoE is as follows:
• The optimal treatment of eosinophilic esophagitis remains uncertain.

Steroid Therapy

• 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 or budesonide may be used as the first-line pharmacologic therapy.
• Children
  • 88–440 mcg/day fluticasone
  • 1 mg/day budesonide
• Adults
  • 880–1760 mcg/day fluticasone
  • 2 mg/day budesonide
• Patients without symptomatic and histologic improvement after topical steroids may be indicated for
  • Long course or higher doses of topical steroids
  • Systemic steroids with prednisone
  • Dietary elimination
  • Endoscopic dilation
• Oropharyngeal and esophageal candidiasis have been reported in patients treated with oral fluticasone.
• Evaluation by an allergist for coexisting atopic disorders, 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.

Dietary Modification

• The dietary strategies are as follows:

• Elemental diet- highly effective in both adults and children, but it is limited by patient tolerability.
• Empiric six-food elimination diet (SFED)- the most common foods that trigger EoE are: soy, fish, cow milk, nuts, eggs, wheat.
• Limited diet driven by allergy testing and patient history- The allergy testing directs diet approach, although effective in the pediatric group has only moderate success in adults.
• The goal of dietary therapy is identification and removal of food antigens and consequently remove the sensitization.
• Diet therapy gives patients an alternative to control their disease, many patients find the idea of managing their sickness by means of removing the nutritional trigger moe appealing than taking a drug to counteract the downstream inflammatory response.
• It is far vital to emphasize that the stern dietary elimination of multiple foods is only for a limited time but the long-term goal is the identify and remove the triggering dietary elements.
• Prolonged deviation from the elimination diet can be managed via intermittent use of quick courses of topical steroids.

Esophageal Dilation

• Dilation is considered safe and effective in relieving the dysphagia in patients with EoE.
• Esophageal dilation has a very good acceptance in patients and it does not influence eosinophilic inflammation.
• Patients with esophageal strictures can be treated by esophageal dilation.
• Esophageal dilation is contraindicated in patients with endoscopic signs of acute inflammation.
• Postprocedural pain is very common in patients with esophageal dilation.
• The use of swallowed topical steroids before dilation reduces the risk of endoscopic complications such as bleeding, perforation, and postprocedural pain.
• Delaying the procedure in patients with strictures can lead to acute food bolus impactions.
• Food impactions should be dealt with carefully as they can cause spontaneous esophageal perforation and procedure-induced complications.

• Pill esophagitis: Stop offending drug
• Radiation esophagitis: Sucralfate, promotility agents, and viscous lidocaine

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

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.