What are the causes of esophagitis?

Causes of Esophagitis

The primary causes of esophagitis include gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), infectious agents, pill-induced injury, and various systemic conditions. 1

Primary Causes

1. Gastroesophageal Reflux Disease (GERD)

• Most common cause of esophagitis worldwide
• Prevalence estimated at 9,283 per 100,000 population 1
• Pathophysiology: Prolonged exposure of esophageal mucosa to acidic gastric contents
• Severity correlates with degree and duration of acid exposure 2
• Can coexist with other forms of esophagitis, particularly EoE 1

2. Eosinophilic Esophagitis (EoE)

• Chronic immune-mediated inflammatory disease
• Prevalence approximately 34.4 per 100,000 population, higher in adults (42.2/100,000) than children (34/100,000) 1
• Diagnostic criteria: ≥15 eosinophils per high-power field in esophageal biopsy 1
• Characterized by symptoms of esophageal dysfunction (dysphagia, food impaction) 3
• Can lead to esophageal remodeling and stricture formation if untreated 1

3. Infectious Esophagitis

• Common causative agents:
  • Fungal: Candida species (most common infectious cause) 1, 4
  • Viral: Herpes simplex virus (HSV), Cytomegalovirus (CMV) 1, 4
  • Bacterial: Less common
• Risk factors: Immunosuppression, antibiotics, steroids, malignancy 4
• Presents with acute onset of dysphagia and odynophagia 4

4. Pill-Induced (Medication) Esophagitis

• Caused by direct mucosal injury from certain medications
• Examples include:
  • Tetracyclines (e.g., doxycycline) 5
  • Bisphosphonates
  • Potassium supplements
  • NSAIDs
  • Iron supplements 1
• Risk increased when medications taken immediately before lying down 5

Secondary Causes

1. Systemic Conditions

• Eosinophilic gastroenteritis/colitis with esophageal involvement 1
• Hypereosinophilic syndrome 1
• Crohn's disease with esophageal involvement 1
• Connective tissue diseases (e.g., systemic sclerosis, Sjögren's syndrome) 1
• Graft-versus-host disease 1
• Vasculitis 1
• Pemphigoid/pemphigus 1

2. Other Esophageal Disorders

• Achalasia 1
• Lymphocytic esophagitis 1
  • Characterized by dense peripapillary lymphocytic infiltrate
  • More common in women over 60 years
  • Presents with dysphagia similar to EoE

Clinical Pearls and Pitfalls

• Important pitfall: GERD and EoE can coexist in the same patient - consider both conditions when evaluating patients with esophageal symptoms 1

• Diagnostic challenge: PPI-responsive esophageal eosinophilia may represent either GERD with more eosinophils than usual or a clinical response to the anti-inflammatory properties of PPIs 1

• Key consideration: The finding of esophageal eosinophilia alone is not sufficient to diagnose EoE - a comprehensive clinical evaluation is required to rule out other causes 1

• Emerging concept: Recent evidence suggests potential inflammatory etiologies for some cases of achalasia, highlighting the complex interplay between immune dysfunction and esophageal motility disorders 1

• Medication timing: Pill-induced esophagitis is more likely when medications are taken immediately before going to bed, emphasizing the importance of proper medication administration 5