Symptoms of Esophagitis
Esophagitis presents with symptoms that vary significantly by age and underlying etiology, with dysphagia and food impaction being the hallmark presentations in adults, while children more commonly exhibit GERD-like symptoms including heartburn, regurgitation, feeding refusal, and vomiting. 1
Age-Specific Symptom Patterns
Children
- GERD-like symptoms are most common, including heartburn and regurgitation (5-82% of cases) 1
- Feeding refusal or intolerance is particularly common in younger children who cannot articulate dysphagia 1
- Vomiting occurs in 8-100% of pediatric cases 1
- Abdominal pain presents in 5-68% of children 1
- Dysphagia and food impaction become increasingly common with age (16-100% for dysphagia; 10-50% for food impaction) 1
- Failure to thrive affects 5-19% of children 1
- Chest pain occurs in 17-20% of pediatric patients 1
Adults
- Intermittent dysphagia is the predominant symptom (29-100% of cases) 1
- Food impaction is extremely common (25-100%), with eosinophilic esophagitis responsible for 50% of esophageal food impaction cases in some institutions 1
- GERD-like symptoms occur less frequently than in children but are still present (7-100%) 1
- Chest pain affects 1-58% of adults 1
- Abdominal pain presents in 3-25% of adult patients 1
- Many adults have long-standing symptoms with recurrent food impactions prior to diagnosis 1
Comprehensive Symptom Spectrum
The 2018 international consensus criteria expanded the recognized symptom profile to include 1:
- Dysphagia (difficulty swallowing)
- Food impaction (acute obstruction requiring emergency intervention)
- Food refusal
- Failure to progress with food introduction (in infants/toddlers)
- Heartburn
- Regurgitation
- Vomiting
- Chest pain
- Odynophagia (painful swallowing) 1, 2
- Abdominal pain
- Malnutrition
Infectious Esophagitis-Specific Symptoms
When esophagitis is due to infection (particularly Candida, HSV, or CMV), additional symptom considerations include 2, 3:
- Odynophagia is particularly prominent in infectious esophagitis 1, 2
- Retrosternal burning pain 2
- Altered taste 2
- Symptoms typically occur in the context of immunosuppression (HIV/AIDS, transplantation, malignancy, prolonged corticosteroid use) 2, 3
Critical Clinical Pitfalls
Symptom Non-Specificity
These symptoms are nonspecific and overlap significantly with GERD, making endoscopy with biopsy essential for definitive diagnosis. 1 The presence of esophageal symptoms alone, without histologic confirmation, is insufficient to diagnose specific forms of esophagitis 1.
Partial Response to Acid Suppression
Symptoms may be only partially responsive to proton pump inhibitors, which should raise suspicion for eosinophilic esophagitis or other non-GERD etiologies. 1 When the primary diagnosis is eosinophilic esophagitis, symptoms are unresponsive or only partially responsive to acid blockade 1.
Atopic Comorbidities as Red Flags
The presence of atopic conditions (asthma, atopic dermatitis, immediate-type food allergies) or family history of eosinophilic esophagitis should significantly increase clinical suspicion. 1
Delayed Diagnosis
Diagnosis is frequently delayed by an average of 4.6 years in adults and 54 months in some series, often because highly suggestive features are not initially recognized 1. This delay can lead to progressive complications including strictures and esophageal remodeling 1.
Treatment Implications Based on Symptoms
Acute Presentations
- Patients with dysphagia or food impaction should proceed directly to endoscopy as first-line evaluation 1
- Patients with heartburn or vomiting may warrant initial medical treatment (e.g., PPI therapy) with endoscopy determined by clinical response 1
Persistent Symptoms Despite Treatment
If symptoms fail to improve after appropriate therapy for infectious esophagitis, repeat endoscopy should be performed to evaluate for refractory infection, alternative diagnoses, or development of resistance. 1, 2
Motility Considerations
In patients with eosinophilic esophagitis who continue experiencing symptoms despite histologic and endoscopic remission, esophageal motility disorders should be considered and further evaluation warranted. 1