Esophagitis is the inflammation of the esophageal mucosa secondary to direct mucosal injury (e.g., gastroesophageal reflux or GERD, substance-induced esophagitis) or to an inflammatory process (e.g., eosinophilic esophagitis). It can also occur secondary to local infection (e.g., esophageal candidiasis, HSV esophagitis, CMV esophagitis), especially in immunosuppressed individuals. The typical manifestation of esophagitis is retrosternal pain (heartburn). Associated features such as regurgitation, odynophagia, or dysphagia may provide clues to the underlying etiology. Coronary artery disease (CAD) may mimic the retrosternal symptoms of esophagitis and should be ruled out if suspected (e.g., chest pain on exertion, presence of ). Empiric pharmacotherapy with a trial of proton pump inhibitors (PPIs) is recommended in patients with typical features of GERD. Inadequate response to empiric therapy or atypical features at presentation (e.g., significant dysphagia, odynophagia, fever), , or should prompt an esophagogastroduodenoscopy (EGD) to directly visualize the esophageal mucosa and obtain biopsies from areas of mucosal abnormalities. Further diagnostics (e.g., esophageal pH monitoring, high-resolution esophageal manometry) should be considered if EGD is inconclusive. Specific management depends on the underlying cause and includes PPIs for GERD, PPIs, dietary restriction and topical steroids for eosinophilic esophagitis, and systemic antifungal or antiviral therapy for infectious esophagitis. Complications of prolonged or severe esophagitis include Barrett esophagus, esophageal strictures, hematemesis, and aspiration.
- Esophagitis: inflammation of the esophageal mucosa that is secondary to direct mucosal injury or to inflammatory infiltrates due to a systemic inflammatory disorder 
- Eosinophilic esophagitis: chronic immune-mediated eosinophil-predominant inflammation of the esophageal mucosa 
- : inflammation of the esophageal mucosa secondary to a local infection; most common in patients with immunosuppression.
- Substance-induced esophagitis: esophageal mucosal injury caused by direct contact with an irritant substance
- Medication-induced esophagitis: a type of substance-induced esophagitis caused by prolonged contact with certain types of oral medications (e.g., antibiotics, antiinflammatory medications, bisphosphonates).
|Etiologies of esophagitis |
- Retrosternal burning chest pain (heartburn)
- May be associated with dyspepsia, regurgitation, belching, and globus sensation
- Features of the underlying etiology, e.g.:
- Assess the pretest probability of the underlying etiology based on a thorough medical history and physical examination.
- Typical features and PPIs : trial of empiric pharmacotherapy with
- Atypical features at presentation or inadequate response to PPI trial: EGD with biopsies of mucosal abnormalities
- Consider cardiovascular causes of retrosternal pain in patients with and/or : See “Chest pain.”
- Diagnosis confirmed on EGD with biopsy: Administer specific treatment (see relevant sections in this article or “GERD” for details).
- Inconclusive EGD
- See also “ .”
- Indication: underlying etiology is most likely GERD, i.e., a patient with all of the following features
- Initiate empiric therapy with a trial of PPIs at standard dosage for 8 weeks.
- See “Antacids and acid suppression medications” for agents, detailed dosages, and pharmacological considerations.
- See “Management of GERD” for details and subsequent management based on response to empiric pharmacotherapy.
Indications (any of the following)
- Age ≥ 60 years with or without
- Multiple or severe regardless of age
- Multiple or major > 5 years) (e.g., duration of symptoms
- Atypical features, such as:
- Suspected GERD with inadequate response to empiric pharmacotherapy
- Nonspecific findings : mucosal erythema, edema, friability, and erosions
- Specific findings
- Infectious esophagitis: pseudomembranes (esophageal candidiasis), punched-out ulcers (herpes esophagitis), or linear ulcers (CMV esophagitis)
- Eosinophilic esophagitis: circumferential mucosal lesions (e.g., rings, corrugations), with possible trachealization
- Medication-induced esophagitis: punched-out ulcers, mild inflammatory changes of the surrounding mucosa
- Barrett esophagus: tongue-shaped projections of salmon pink mucosa in the lower third of the esophagus
- Esophageal cancer: intraluminal ulceroproliferative friable mass
- Biopsies should be obtained from any area of mucosal irregularity seen on EGD.
- Histopathologic findings can often determine the etiology, e.g.:
Additional diagnostics (not routinely required)
Clinical features 
- Odynophagia, dysphagia (characteristic)
- Heartburn, regurgitation
- Lesions in the oral mucosa (e.g., ulcers, thrush) 
- Retrosternal chest pain
- Systemic signs of infection (e.g., fever)
- Fungal: Candida spp. (most common)
- Viral: CMV, HSV (HSV-1)
- Uncommon: bacterial esophagitis , parasitic esophagitis
Infectious esophagitis is most commonly seen in patients with immunosuppression (resulting from, e.g., HIV, malignancies, transplantation, dialysis). A diagnosis of infectious esophagitis in patients with no known comorbidities should prompt studies for immunosuppression.
Diagnostics and treatment
|Diagnostics and treatment of infectious esophagitis |
|Esophageal candidiasis ||Herpes esophagitis (mainly HSV-1)||CMV esophagitis|
|Diagnostics||Endoscopic findings|| |
|Histopathologic findings|| |
|Treatment||General measures|| |
| Specific treatment || |
Clinical features 
- Dysphagia, food bolus impaction
- Symptoms can be worsened by ingestion of food containing allergens.
- Associated features: atopy (e.g., asthma, rhinitis, atopic dermatitis, alimentary allergies)
- Endoscopic findings
- Histopathologic findings 
- First-line: Proton pump inhibitors (PPIs) at standard dose of PPIs for 8 weeks; see “Acid suppression medications” for details on agents and dosages.
- Second-line ; : topical steroids (swallowed aerosolized steroids)
- Dietary elimination (avoiding allergens): Exclude certain protein groups (e.g., milk, soy, nuts) from the diet to reduce the inflammatory response in the GI tract.
- Esophageal dilation: Consider for patients with a narrow stricture or diffuse narrowing of the esophagus.
Long-term maintenance therapy (dietary elimination and/or pharmacological therapy) is often required to maintain remission. 
Medication-induced esophagitis 
- Etiology: direct mucosal injury caused by prolonged contact with a certain drug
- Treatment: Most cases are self-limiting.