What is the treatment for esophagitis?

Treatment of Esophagitis

The treatment of esophagitis depends critically on the underlying etiology: for erosive esophagitis due to GERD, proton pump inhibitors (PPIs) are first-line therapy; for eosinophilic esophagitis (EoE), topical corticosteroids are the preferred initial treatment, though PPIs should also be considered as an early option; and for infectious esophagitis, pathogen-specific antimicrobial therapy is required. 1, 2

Erosive Esophagitis (GERD-Related)

Initial Treatment

• PPIs are strongly recommended as first-line therapy for erosive esophagitis, with healing rates exceeding 80% after 8 weeks of treatment in most patients 2, 3
• Standard PPI dosing (e.g., omeprazole 20-40 mg daily or lansoprazole 30 mg daily) should be administered for 4-8 weeks initially 4, 5
• For patients with moderate to severe erosive esophagitis (Los Angeles grade C or D), 8 weeks of therapy is more effective than 4 weeks, with healing rates approaching 90% 3, 4
• Patients who fail to heal after 8 weeks may benefit from an additional 8-week course of PPI therapy 4, 5

Maintenance Therapy

• Long-term daily PPI therapy is strongly recommended for patients with healed erosive esophagitis to prevent recurrence 2
• Recurrence rates are extremely high (82% at 6 months) when PPIs are discontinued 6
• On-demand or intermittent PPI dosing is NOT recommended for patients with a history of erosive esophagitis, as recurrence rates of erosive disease are unacceptably high compared to continuous therapy 2
• Maintenance therapy should be titrated to the lowest effective dose based on symptom control, but less than daily dosing is discouraged 2

Special Populations

• Patients with severe esophagitis or persistent symptoms are at higher risk for incomplete healing and require closer monitoring 3
• For PPI-refractory erosive esophagitis, consider higher doses or twice-daily dosing before endoscopic evaluation 2

Eosinophilic Esophagitis (EoE)

First-Line Treatment Options

• Topical corticosteroids are recommended as first-line treatment due to high efficacy in achieving both clinical and histological remission 1
• PPIs should be considered as a potential early or initial treatment due to low cost, good safety profile, convenience, and substantial evidence of efficacy 2, 1
• PPIs should be given twice daily for at least 8-12 weeks prior to assessment of histological response 1
• Swallowed topical steroids or dietary elimination may also be considered as initial therapy 2

Alternative and Adjunctive Therapies

• Six-food elimination diet is effective, with higher histological remission rates than two or four food elimination diets 1
• Support from an experienced dietitian throughout elimination and reintroduction is strongly recommended 1
• If diet or steroid therapy fails on follow-up endoscopy with biopsy, PPI therapy should be considered as there is good likelihood of success 2
• Some patients may require combination therapy with both a PPI and anti-inflammatory treatment (dietary elimination or topical steroids) when GERD and EoE coexist 2

Management of Fibrostenotic Disease

• Endoscopic dilation is effective for improving dysphagia in patients with strictures, using either balloon or bougie dilators 1
• Clinical outcomes are better when therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids 1

Monitoring and Follow-up

• After initiation of therapy, endoscopy with biopsy while on treatment is recommended to assess response, as symptoms may not correlate with histological activity 1, 2
• Regular clinic visits should monitor symptoms, compliance, and adverse effects 2
• Patients refractory to treatment or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 1

Treatments NOT Recommended

• Immunomodulators, monoclonal antibody therapies (except emerging biologics for refractory disease), sodium cromoglycate, montelukast, and antihistamines are not recommended for EoE management 1

Infectious Esophagitis

Candidal Esophagitis

• Systemic antifungal therapy is required for effective treatment 2
• A 14-21 day course of either fluconazole (100 mg/day orally) or itraconazole solution (200 mg/day orally) is highly effective 2
• A diagnostic trial of antifungal therapy is often appropriate before endoscopy when symptoms suggest esophageal candidiasis 2
• For fluconazole-refractory disease, itraconazole solution (>200 mg/day orally) should be used 2
• Intravenous amphotericin B (0.3-0.7 mg/kg/day) may be used for otherwise refractory disease 2

Viral and Bacterial Esophagitis

• Treatment is pathogen-specific and requires identification of the causative organism 7
• Cytomegalovirus and herpes simplex virus are other important causes requiring specific antiviral therapy 7

Common Pitfalls and Caveats

• Do not assume symptom resolution equals histological healing in EoE—endoscopic assessment is necessary 1, 2
• Avoid on-demand PPI therapy in patients with documented erosive esophagitis—continuous therapy is required to prevent recurrence 2
• Do not overlook coexisting GERD and EoE—some patients require treatment for both conditions simultaneously 2
• Patients with EoE are at increased risk for esophageal tears and perforation during endoscopy 2
• The psychological impact of dietary therapy in EoE should be discussed with patients 1
• Topical corticosteroids for EoE have been associated with esophageal candidiasis, requiring monitoring 2