What is the initial workup and management for a patient with suspected esophagitis?

Esophagitis Workup

Initial Diagnostic Approach

For patients with suspected esophagitis presenting with typical symptoms (heartburn, dysphagia, regurgitation, chest pain), begin with empiric proton pump inhibitor (PPI) therapy at standard once-daily dosing for 4-8 weeks before pursuing endoscopy, unless alarm features are present. 1

When to Proceed Directly to Endoscopy

Perform urgent or early endoscopy in the following scenarios:

• Food bolus obstruction: Requires urgent gastroenterology referral and endoscopy on the next available list or as an immediate emergency, depending on clinical presentation 1
• Dysphagia: This is an alarm symptom requiring endoscopy to exclude stricture, malignancy, or eosinophilic esophagitis 1, 2
• Chest pain after cardiac evaluation: Once ischemic heart disease has been adequately excluded, proceed with endoscopy if empiric twice-daily PPI therapy for 4 weeks fails 1
• Children with PPI-refractory symptoms: Endoscopy with biopsies should be performed to exclude eosinophilic esophagitis 1
• Adults with PPI-refractory symptoms PLUS dysphagia or atopy: These features increase the likelihood of eosinophilic esophagitis 1

Empiric PPI Trial Protocol

Start with omeprazole 20 mg once daily (or equivalent PPI) taken before meals for 4-8 weeks. 1, 3

• If symptoms persist after 4-8 weeks of once-daily therapy, escalate to twice-daily dosing (before morning and evening meals) 1, 4
• Patients failing twice-daily PPI therapy after 8 weeks are treatment failures and require endoscopy with biopsies 1, 4
• Do not add H2-receptor antagonists to twice-daily PPI therapy, as there is no evidence of improved efficacy 1, 4

Endoscopic Evaluation

Biopsy Protocol

Obtain at least 6 biopsies from different anatomical sites within the esophagus, even if the mucosa appears normal endoscopically. 1

• Take biopsies from proximal, mid, and distal esophagus (minimum 2 from each level) 1
• All children undergoing endoscopy for upper GI symptoms should have esophageal biopsies to diagnose eosinophilic esophagitis 1
• In food bolus obstruction cases, biopsies must be taken at index endoscopy 1

Diagnostic Criteria for Eosinophilic Esophagitis

• ≥15 eosinophils per 0.3 mm² (high-power field) in any biopsy specimen 1
• Must be accompanied by other histological features: basal cell hyperplasia, edema (spongiosis), eosinophil microabscesses, eosinophil layering, eosinophil degranulation, or subepithelial sclerosis 1
• Withdraw PPIs for at least 3 weeks prior to endoscopy if eosinophilic esophagitis is suspected and accurate diagnosis is needed 1

Important Caveat About PPI-Responsive Esophageal Eosinophilia

Eosinophilic esophagitis that responds to PPI therapy is the same disease as PPI-non-responsive eosinophilic esophagitis 1. Additionally, GERD and eosinophilic esophagitis can coexist in the same patient 1. This means that finding pathologic acid reflux does not exclude eosinophilic esophagitis, and vice versa.

Management Based on Endoscopic Findings

Erosive Esophagitis (Los Angeles Grades A-D)

• PPIs are superior to H2-receptor antagonists for healing erosive esophagitis, with faster and more complete healing 1, 5
• Standard doses: omeprazole 20 mg daily, lansoprazole 30 mg daily, or esomeprazole 40 mg daily for 4-8 weeks 3, 5, 2
• 80% of patients with healed erosive esophagitis will relapse within one year without maintenance therapy 5
• Maintenance PPI therapy is appropriate for preventing relapse 5

Non-Erosive Reflux Disease (NERD)

• Represents 40% of patients with PPI-refractory symptoms who undergo complete evaluation 6
• Requires confirmation with 24-hour ambulatory pH monitoring (positive if % total time pH <4 is >5%) 6
• Treat with standard-dose PPI therapy 1

Eosinophilic Esophagitis

• PPI therapy should be considered as initial treatment due to low cost, good safety profile, and convenience 1
• Alternative first-line options include topical corticosteroids or dietary elimination 1
• If diet or steroid therapy fails, try PPI therapy, as there is a good chance of success 1
• Maintenance therapy with topical steroids reduces the risk of recurrent food bolus obstruction 1

Evaluation of PPI-Refractory Symptoms

When symptoms persist despite twice-daily PPI therapy, multimodality evaluation changes the diagnosis in 34.5% of cases and guides alternative therapies in 42% 6. The following tests should be considered:

Structured Diagnostic Algorithm

1. Repeat endoscopy with adequate biopsies if initial histology was not diagnostic but high suspicion exists for eosinophilic esophagitis 1
2. Esophageal manometry to exclude achalasia (2.5% of PPI-refractory patients) or other dysmotility disorders (5.8%) 6
3. 24-hour ambulatory pH monitoring (off PPI for at least 3 weeks) to confirm or exclude pathologic acid reflux 1, 6
4. Gastric emptying scan if symptoms suggest gastroparesis (positive if >10% retention at 4 hours and >70% at 2 hours) 6

Expected Diagnostic Outcomes in PPI-Refractory Patients

Based on comprehensive evaluation 6:

• 40% have non-erosive reflux disease
• 19.3% have erosive esophagitis (inadequately treated)
• 16% have functional heartburn (normal endoscopy and pH studies)
• 5.5% have eosinophilic esophagitis
• 5.5% have Barrett's esophagus
• 5.8% have gastroparesis
• 8.3% have motility disorders (achalasia or other dysmotility)

Common Pitfalls to Avoid

• Do not use metoclopramide as monotherapy or adjunctive therapy for GERD or esophagitis 1, 4
• Do not assume dysphagia indicates severe esophagitis: 37% of patients with erosive esophagitis have dysphagia, but it is not a reliable predictor of severity 2
• Do not miss eosinophilic esophagitis in children: All children undergoing endoscopy for upper GI symptoms require esophageal biopsies 1
• Do not overlook overlap diagnoses: 67% of eosinophilic esophagitis patients, 75% of gastroparesis patients, and 48% of achalasia patients have concomitant pathologic acid reflux 6
• Do not perform endoscopy in adults with typical GERD symptoms refractory to PPIs unless dysphagia or atopy is present, as eosinophilic esophagitis prevalence is low in this population 1
• Persistent dysphagia after 4 weeks of PPI therapy may indicate failed healing and warrants repeat endoscopy 2