What is the management approach for multiple diminutive plaques in the upper third of the esophagus found on Esophagogastroduodenoscopy (EGD)?

Management of Multiple Diminutive Plaques in the Upper Third of the Esophagus Found on EGD

Multiple diminutive plaques in the upper third of the esophagus most likely represent esophageal candidiasis and should be treated with oral fluconazole 200 mg on the first day followed by 100 mg daily for at least 2-3 weeks.

Differential Diagnosis

When multiple diminutive plaques are identified in the upper third of the esophagus during EGD, several conditions should be considered:

1. Esophageal candidiasis - Most common cause of white plaques in the esophagus
2. Eosinophilic esophagitis - Can present with white exudates, though typically affects the mid to distal esophagus
3. Esophageal intramural pseudodiverticulosis - Rare condition that can be confused with eosinophilic esophagitis 1
4. Esophageal xanthoma - Rare benign lesion 2

Diagnostic Approach

The finding of multiple diminutive plaques requires:

• Biopsy of the lesions - Essential for definitive diagnosis to distinguish between infectious, inflammatory, or neoplastic processes
• Adequate mucosal visualization - Ensure proper cleansing and inspection of the esophageal mucosa 3
• Documentation of location, size, and appearance - Important for follow-up assessment

Management Algorithm

Step 1: Presumptive Treatment for Candidiasis

• First-line therapy: Fluconazole 200 mg orally on day 1, followed by 100 mg once daily 4
• Duration: Minimum of 3 weeks and at least 2 weeks following resolution of symptoms 4
• Higher doses: Up to 400 mg/day may be used based on clinical judgment of response 4

Step 2: Follow-up Based on Biopsy Results

If Candidiasis Confirmed:

• Complete the full course of antifungal therapy
• Consider risk factors assessment (immunosuppression, HIV, diabetes)
• Follow-up EGD may be warranted in 4-6 weeks if symptoms persist

If Eosinophilic Esophagitis:

• Consider topical glucocorticosteroids (strong recommendation) 3
• Consider proton pump inhibitor or elimination diet therapy (conditional recommendations) 3
• Esophageal dilation may be needed if strictures are present 3

If Normal Findings or Non-specific Esophagitis:

• Empiric PPI therapy may be beneficial even when testing is negative 5
• Follow-up EGD in 6-8 weeks if symptoms persist

Special Considerations

• Immunocompromised patients: May require longer treatment courses and closer follow-up
• Renal impairment: Fluconazole dosage adjustment required for patients with creatinine clearance ≤50 mL/min 4
• Pediatric patients: Dosing should be weight-based (6 mg/kg on first day, followed by 3 mg/kg daily) 4

Pitfalls to Avoid

1. Inadequate visualization: Ensure proper mucosal cleansing and inspection of the entire esophagus 3
2. Missing alternative diagnoses: Always obtain biopsies of suspicious lesions, as visual inspection alone has limited sensitivity (40.6%) for detecting dysplasia or chronic esophagitis 6
3. Premature discontinuation of therapy: Esophageal candidiasis requires treatment for a minimum of three weeks and at least two weeks following symptom resolution 4
4. Overlooking underlying conditions: Consider factors that may predispose to esophageal candidiasis (immunosuppression, diabetes, antibiotics, inhaled corticosteroids)

Follow-up Recommendations

• Clinical reassessment after 2-3 weeks of therapy
• Consider repeat EGD if symptoms persist despite appropriate therapy
• If symptoms resolve but recur, investigate for underlying immunodeficiency or other predisposing conditions

The management of esophageal plaques should focus on both symptom resolution and prevention of complications, with the goal of improving quality of life and reducing morbidity associated with esophageal disease.