What is the initial treatment for a patient with esophagitis?

Treatment of Esophagitis

The initial treatment for esophagitis depends critically on the underlying etiology: for erosive esophagitis (GERD-related), start with a standard-dose proton pump inhibitor (PPI) once daily 30-60 minutes before breakfast for 4-8 weeks; for eosinophilic esophagitis, initiate either PPI therapy (omeprazole 20 mg twice daily) or topical corticosteroids for 8-12 weeks; and for infectious esophagitis in immunocompromised patients, begin systemic antifungal therapy with fluconazole or itraconazole for 14-21 days. 1, 2, 3

Erosive Esophagitis (GERD-Related)

First-Line Pharmacologic Management

• PPIs are the most effective first-line therapy for erosive esophagitis, with healing rates exceeding 80% after 8 weeks of treatment. 1, 4
• Standard dosing includes omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, pantoprazole 40 mg, or rabeprazole 20 mg once daily. 2, 5
• Critical timing: PPIs must be taken 30-60 minutes before the first meal of the day to coincide with postprandial peak in active proton pumps for maximum efficacy. 2, 5
• Treatment duration should be 4-8 weeks initially, with endoscopic reassessment if symptoms persist. 5

Long-Term Management Strategy

• Long-term daily PPI therapy is mandatory for patients with healed erosive esophagitis to prevent recurrence, as recurrence rates exceed 80% within 6 months when PPIs are discontinued. 1, 6
• On-demand or intermittent PPI dosing is contraindicated in erosive esophagitis due to unacceptably high recurrence rates. 1, 2
• For PPI-refractory disease, escalate to higher doses or twice-daily dosing before pursuing endoscopic evaluation. 1

Severity-Based Dosing Considerations

• Grade 2 esophagitis (mild ulcerative): 87% healing with 20 mg omeprazole, 97% with 40 mg at 4 weeks. 6
• Grade 3 esophagitis (moderate): 67% healing with 20 mg, 88% with 40 mg. 6
• Grade 4 esophagitis (Barrett's ulcers/confluent ulceration): Less than 50% healing with either dose, requiring longer treatment courses. 6

Eosinophilic Esophagitis (EoE)

First-Line Treatment Options

• PPIs should be considered as initial treatment due to low cost, excellent safety profile, convenience, and substantial evidence of efficacy, with 30-50% achieving histological remission. 1, 3, 7
• Recommended dosing: omeprazole 20 mg twice daily for 8-12 weeks. 3
• Topical corticosteroids are highly effective as first-line therapy, achieving histological and clinical remission in 60-87% of patients. 1, 3, 7

Dietary Management

• Six-food elimination diet (dairy, wheat, egg, soy, nuts, seafood) achieves 79% histological remission but has lower compliance. 1, 3, 7
• Four-food elimination diet achieves 60% remission, two-food elimination achieves 43% remission. 7
• Amino acid-based elemental diet achieves over 90% histological remission but is only feasible for limited duration. 7

Critical Monitoring Requirement

• Endoscopy with biopsy while on treatment is mandatory to assess response, as symptoms do not correlate with histological activity. 1, 3
• Repeat endoscopy should occur after 8-12 weeks of therapy to document histological response. 3

Management of Fibrostenotic Disease

• Endoscopic dilation (balloon or bougie) is effective and safe for improving dysphagia in patients with strictures. 8, 1, 3
• Combined approach of dilation with topical steroids yields superior clinical outcomes. 3
• Important caveat: Dilation does not address underlying esophageal inflammation and must be combined with anti-inflammatory therapy. 8

Maintenance Therapy

• For patients achieving histological response, continuation of PPIs or topical corticosteroids is recommended, as relapse rates are high after withdrawal. 8, 3
• Long-term maintenance therapy prevents recurrent dysphagia, food impaction, and esophageal stricture formation. 8

Infectious Esophagitis (Immunocompromised Patients)

Candidal Esophagitis

• Systemic antifungal therapy with fluconazole or itraconazole solution for 14-21 days is highly effective. 1
• HIV-positive patients with esophageal symptoms may be treated empirically with antifungal therapy without initial diagnostic examination. 8
• Patients with severe symptoms at presentation or persistent symptoms should undergo endoscopy for specimen acquisition. 8

Diagnostic Approach

• Biphasic esophagram is more accurate than single-contrast esophagram for detecting ulcers or plaques associated with infectious esophagitis. 8
• Endoscopy is preferred when available due to ability to obtain specimens for histology, cytology, immunostaining, or culture. 8
• Endoscopic or radiographic appearance alone does not accurately predict diseases other than Candida esophagitis; diagnosis requires specimen acquisition. 8

Herpes Simplex and Cytomegalovirus

• Patients with radiographically diagnosed herpes esophagitis may be treated with antiviral agents without endoscopic evaluation. 8
• Endoscopy is warranted for patients with giant esophageal ulcers to differentiate cytomegalovirus from HIV ulcers and begin appropriate therapy. 8

Common Pitfalls and Caveats

Critical Errors to Avoid

• Never assume symptom resolution equals histological healing in EoE—endoscopic assessment is necessary. 1, 3
• Never use on-demand PPI therapy in patients with documented erosive esophagitis—continuous therapy is required to prevent recurrence. 1, 2
• Do not overlook coexisting GERD and EoE, as some patients require treatment for both conditions simultaneously. 1
• Do not discontinue PPI therapy in erosive esophagitis after initial healing, as 82% will relapse within 6 months. 6

Adjunctive Lifestyle Modifications (for GERD-related esophagitis)

• Avoid recumbency for 2-3 hours after meals and elevate the head of the bed. 2
• Weight loss is recommended if overweight or obese. 2
• Limit fat intake to less than 45 grams per day and avoid late evening meals. 2
• Avoid individual trigger foods on a patient-specific basis rather than blanket dietary restrictions. 2