What is the treatment for radiation esophagitis?

Treatment of Radiation Esophagitis

The treatment of radiation esophagitis should focus on symptomatic management with topical anesthetics such as viscous lidocaine, pain control following the WHO analgesia ladder, and nutritional support, as there is no proven preventive therapy that significantly reduces this common side effect of thoracic radiotherapy. 1, 2

Initial Assessment and Management

• Evaluate for esophageal candidosis through physical examination of mouth and oropharynx, as it occurs in up to 16% of patients with radiation-induced esophagitis 1, 2
• Implement systematic pain management using topical anesthetics such as viscous lidocaine, coating agents (glycyrrhetinic acid, povidone, sodium hyaluronate), carboxymethylcellulose suspension, and sucralfate for direct pain relief 1, 3
• Follow the modified WHO analgesia ladder for pain control, using soluble or liquid forms of medication when possible 1
• Avoid NSAIDs such as indomethacin and naproxen, as they have shown no beneficial effect on esophagitis and may worsen symptoms 1, 4

Nutritional Support

• Provide early referral to a nutrition team for patients at risk of malnutrition 1, 2
• Ensure adequate caloric and protein intake through dietary modifications including texture modification and food fortification 1, 3
• Consider oral nutritional supplements and multivitamins with trace elements 1
• If oral intake is severely compromised, consider enteral feeding tubes to prevent weight loss, decreased physical performance, and dehydration 2, 3
• Nasogastric tube (NGT) is generally preferred over PEG for temporary feeding as it is associated with less dysphagia and earlier weaning after completion of radiotherapy 3

Management of Specific Complications

• If esophageal candidosis is suspected, especially in patients with delayed recovery of esophagitis, initiate appropriate antifungal therapy 1, 2
• For suspected reflux contributing to symptoms, consider proton pump inhibitors 5
• If esophageal spasm occurs, calcium antagonists might help reduce symptoms 5
• For strictures that may develop as late complications, consider endoscopic dilatation following BSG and NICE guidelines 1, 6

Lifestyle Modifications

• Advise patients to avoid irritants that can worsen esophagitis, including alcohol, bulky food, spicy foods, very hot or cold foods, and citrus products 2, 3
• Recommend small, frequent meals of soft or pureed consistency to minimize discomfort during swallowing 2
• Encourage professionally supervised swallowing exercises to maintain function even during periods of severe dysphagia 3

Expected Course and Monitoring

• Acute radiation-induced esophagitis typically begins during the third week of treatment, peaks about 2 weeks after completion, and usually resolves within 8 weeks 1, 2
• Monitor nutritional status continuously, with particular attention to weight loss 2, 3
• If symptoms persist beyond 8 weeks post-treatment, consider additional evaluation for complications such as stricture formation or persistent candidosis 2

Ineffective Treatments to Avoid

• Sucralfate has not demonstrated significant benefit in randomized controlled trials for radiation esophagitis prevention 1
• 5-amino-salicylic acid and related compounds (mesalazine and olsalazine) are not recommended to prevent gastrointestinal mucositis 1
• Glutamine supplementation does not prevent radiation-induced diarrhea and is not recommended for prevention of gastrointestinal mucositis 1

Special Considerations for Concurrent Chemoradiotherapy

• Be aware that concurrent chemoradiotherapy significantly increases the risk and severity of esophagitis compared to radiation alone 1, 7
• The incidence of grade 3-4 acute esophagitis may be as high as 30% with concurrent chemoradiation versus <5% with radiotherapy alone 1
• More intensive supportive care may be needed for patients receiving concurrent chemotherapy and radiotherapy 1