What are the treatment options for esophagitis?

Treatment Options for Esophagitis

The treatment of esophagitis should primarily focus on proton pump inhibitors (PPIs) as first-line therapy, followed by topical corticosteroids if PPI therapy fails, with dietary interventions and dilation reserved for specific cases. 1

Types of Esophagitis and First-Line Treatments

Eosinophilic Esophagitis (EoE)

• First-line therapy: Proton pump inhibitors (PPIs)
  • Achieve histologic remission in approximately 41.7% of patients 2
  • Examples: omeprazole, lansoprazole
  • Duration: 8-12 weeks initial treatment 3, 4

Reflux Esophagitis

• First-line therapy: Proton pump inhibitors
  • Lansoprazole 30 mg daily shown to be more effective than ranitidine for healing erosive esophagitis 3
  • Omeprazole indicated for 4-8 weeks of treatment 4

Infectious Esophagitis

• Treatment based on causative organism:
  • Candida (most common): Fluconazole or other antifungal agents
  • Viral (HSV, CMV): Appropriate antiviral medications
  • Bacterial: Targeted antibiotics 5

Second-Line Treatments for EoE

Topical Corticosteroids

• Indicated when PPI therapy fails
• Histologic remission achieved in 64.9% of patients (vs 13.3% for placebo) 2
• Options include:
  • Fluticasone (swallowed)
  • Budesonide (viscous suspension)
• Common side effect: Esophageal candidiasis 1

Dietary Interventions

Elemental Diet

• Achieves histologic remission in 93.6% of patients 1
• Practical limitations:
  • Poor palatability
  • May require feeding tube
  • Social isolation
  • High cost
  • Interference with oral motor skills in children 1

Six-Food Elimination Diet

• Eliminates milk, wheat, egg, soy, nuts, and seafood
• Achieves histologic remission in approximately 68% of patients 1
• Less restrictive than elemental diet but still challenging for adherence

Endoscopic Dilation

• Reserved for patients with:
  • Esophageal strictures
  • Persistent dysphagia despite medical therapy
• Clinical improvement in 87% of patients 1
• Risks:
  • Perforation (0.4%)
  • Hospitalization (1.2%)
  • Significant bleeding (0.1%) 1

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis through endoscopy with biopsy
   • Assess severity of symptoms and presence of strictures

2. First-Line Treatment:

   • Start PPI therapy (omeprazole 20-40 mg daily or lansoprazole 30 mg daily)
   • Continue for 8-12 weeks

3. Evaluate Response:

   • If symptoms resolve: Continue maintenance therapy
   • If symptoms persist: Proceed to second-line options

4. Second-Line Options:

   • For EoE:
     • Topical corticosteroids OR
     • Dietary therapy (elimination diet or elemental formula)
   • For persistent strictures: Consider endoscopic dilation

5. Maintenance Therapy:

   • Continue effective medication at lowest effective dose
   • For EoE: Repeat endoscopy every 2-3 years to monitor disease progression 1

Important Considerations and Pitfalls

• Treatment goals should address both symptom relief and histologic remission in EoE, though these may not occur concurrently 1
• Monitor for complications of therapy, especially esophageal candidiasis with topical steroids
• Long-term maintenance is typically necessary as disease recurrence is common when therapy is discontinued 1
• Avoid delay in treatment as chronic inflammation may lead to esophageal remodeling and stricture formation
• Consider consultation with allergist when implementing dietary therapy for EoE 1

The treatment approach should be guided by the specific type of esophagitis, severity of symptoms, presence of complications, and patient's ability to adhere to therapy, with the ultimate goal of improving quality of life and preventing long-term complications.