What are the causes of distal esophagus disease?

From the Guidelines

The distal esophagus can be affected by several conditions, with gastroesophageal reflux disease (GERD) being the most common cause of symptoms and pathology in this region, as reported in a recent study 1. GERD occurs when stomach acid flows back into the esophagus, causing irritation and inflammation of the esophageal lining. Other important causes include:

• Barrett's esophagus, which is a precancerous condition resulting from chronic acid exposure
• Esophageal adenocarcinoma, which often develops in the distal esophagus
• Achalasia, a motility disorder affecting the lower esophageal sphincter
• Hiatal hernias, where part of the stomach protrudes through the diaphragm into the chest, can also affect the distal esophagus and contribute to reflux symptoms
• Infectious esophagitis (from Candida, herpes, or cytomegalovirus), especially in immunocompromised patients, can involve the distal esophagus, with Candida esophagitis being the most commonly encountered infectious esophagitis, as noted in a recent clinical practice update 2
• Eosinophilic esophagitis, an allergic inflammatory condition, may affect the entire esophagus including the distal portion, with a recent guideline recommending treatment with proton pump inhibitors, diet, and topical steroids 3

Treatment depends on the specific condition but often includes:

• Proton pump inhibitors like omeprazole 20-40mg daily for GERD
• Antifungals, such as fluconazole, for infectious causes, with a recommended dose of 200 to 400 mg per day for 14 to 21 days 2
• Surgical interventions for structural abnormalities and advanced cancers
• Dietary therapy with elimination of causative allergens, or topical corticosteroids may provide a durable long-term solution for eosinophilic esophagitis, as suggested by a recent study 4

From the Research

Causes of Distal Esophagus Disease

The causes of distal esophagus disease can be attributed to several factors, including:

• Gastroesophageal reflux disease (GERD), a chronic relapsing disease characterized by pathological exposure of the distal esophagus to gastric acid 5
• Peptic stricture and esophagitis, which can be caused by the reflux of stomach contents into the esophagus or oral cavity 6
• Erosive esophagitis, esophageal strictures, and Barrett esophagus, a precursor to esophageal adenocarcinoma, which are all complications of GERD 7, 8
• The refluxate, esophageal defenses, and factors that promote pathologic reflux into the esophagus, which all contribute to the development of GERD 9

Risk Factors

Some of the risk factors that contribute to the development of distal esophagus disease include:

• The interplay of chemical, mechanical, psychologic, and neurologic mechanisms, which contribute to symptom presentation, diagnosis, and treatment of GERD 9
• The caustic effects of refluxed acid and pepsin on the esophageal mucosa, which can result in peptic esophageal erosion and ulceration 8
• The retrograde flow of refluxate into the esophagus, which can cause symptoms and complications of GERD 9

Complications

The complications of distal esophagus disease can include:

• Erosive esophagitis, esophageal strictures, and Barrett esophagus, which are all complications of GERD 7, 8
• Hemorrhage, perforation, and penetration into the airway, which are uncommon complications of esophageal ulcers 8
• Dysphagia, which can be caused by peptic stricture and esophagitis 6