What is the management of esophagitis following radiation therapy?

From the Guidelines

Management of radiation-induced esophagitis involves a multimodal approach focusing on symptom relief and supportive care, with the administration of a proton pump inhibitor at a daily dose of 40 mg, from the beginning of radiotherapy up to 3 months after the end, being recommended 1. For mild to moderate esophagitis, start with dietary modifications including soft, bland foods, avoiding irritants like alcohol, spicy foods, and acidic beverages, and consuming smaller, more frequent meals. Pain management should include viscous lidocaine 2% (10-15 mL swished and swallowed before meals), sucralfate suspension (1 g four times daily), and proton pump inhibitors such as omeprazole 20-40 mg daily or pantoprazole 40 mg daily. For more severe pain, systemic analgesics like acetaminophen or, if necessary, opioids may be required. Maintaining adequate hydration and nutrition is crucial; nutritional supplements or temporary enteral feeding may be needed in severe cases. Antifungal therapy with fluconazole 100-200 mg daily for 7-14 days should be considered if Candida infection is suspected, as esophageal candidosis frequently occurs in patients with grade 2 or more esophagitis 1. These interventions work by providing mucosal protection, reducing acid reflux that can exacerbate symptoms, and directly addressing pain and inflammation. Most cases of radiation esophagitis improve within 2-3 weeks after completion of radiation therapy, but management should continue until symptoms resolve. Enteral nutrition may be supplied for short periods via nasogastric tubes or for longer periods via percutaneous gastrostomies, with percutaneous endoscopic gastrostomies (PEG) compared to radiologically inserted gastrostomies (RIG) appearing to be associated with a lower risk of peritonitis and mortality 1. In high-risk situations, prophylactic tube feeding may maintain nutritional status and avoid interruption of treatment 1. Smoking cessation should also be actively supported in all patients, as it may improve long-term survival, decrease side effects, and risk of developing second primary cancers 1.

Some key points to consider in the management of radiation-induced esophagitis include:

• The importance of early intervention and supportive care to prevent complications and improve outcomes
• The need for individualized nutritional counseling and support to maintain adequate hydration and nutrition
• The use of proton pump inhibitors and other medications to manage symptoms and prevent further complications
• The consideration of antifungal therapy in patients with suspected Candida infection
• The potential benefits of enteral nutrition and prophylactic tube feeding in high-risk patients
• The importance of smoking cessation in improving outcomes and reducing the risk of complications.

Overall, the management of radiation-induced esophagitis requires a comprehensive and multidisciplinary approach, with a focus on symptom relief, supportive care, and prevention of complications.

From the Research

Management of Esophagitis after Radiation

• The management of esophagitis after radiation involves various treatment options, including medication and dietary changes.
• According to a study published in 1994 2, sucralfate is useful in the management of acute radiation oesophagitis, with significant relief of symptoms within 7 days of treatment and most ulcers healed by 12 days of treatment.

Medical Treatments

• A systematic review published in 2007 3 compared the effectiveness of proton pump inhibitors (PPIs), H2 receptor antagonists (H2RAs), prokinetic therapy, sucralfate, and placebo in healing oesophagitis or curing reflux symptoms.
• The review found that PPI therapy is the most effective therapy in oesophagitis, with a statistically significant benefit compared to placebo and H2RA therapy.
• Another study published in 2012 4 found that amifostine is the only drug to have a proven radioprotective efficacy in the management of esophagitis.

Dietary Changes and Other Treatments

• The medical management of esophagitis also involves a diet excluding irritant food, medication against gastroesophageal reflux, analgesic treatment, and management of dehydration and denutrition by enteral feeding 4.
• A review published in 2021 5 discussed the treatment of eosinophilic esophagitis, which includes proton pump inhibitors, topical steroid preparations, dietary therapy, and endoscopic dilation.
• A systematic review published in 2001 6 compared the effectiveness of esomeprazole with other proton pump inhibitors in the healing of reflux oesophagitis, finding that esomeprazole has higher healing rates than omeprazole at 4 and 8 weeks.