What is the best course of action for a patient with a history of chronic liver disease and recently resolved esophageal candidiasis who is now experiencing dysphagia?

Dysphagia After Resolved Esophageal Candidiasis in Chronic Liver Disease

In a patient with chronic liver disease and recently resolved esophageal candidiasis who now has persistent dysphagia, proceed immediately with endoscopy to exclude structural complications (stricture, residual inflammation) and obtain biopsies to rule out eosinophilic esophagitis, followed by high-resolution manometry and biphasic esophagram if endoscopy is unrevealing. 1, 2

Immediate Diagnostic Approach

First-Line: Upper Endoscopy with Biopsy

• Endoscopy is the priority to directly visualize the esophageal mucosa and identify structural causes including strictures, residual candidiasis, or other mucosal pathology 1, 3
• Esophageal candidiasis can cause esophageal stricture formation through chronic inflammation, tissue damage, fibrosis, and scarring—a rare but serious complication that presents with persistent dysphagia 4
• Obtain 5-6 biopsies even if mucosa appears normal to exclude eosinophilic esophagitis, which can be latent and occurs in up to 9% of patients with dysphagia 2
• Evaluate for recurrent or persistent candidiasis, as 16% of patients may have esophageal candidosis that may not correlate with clinical symptoms 1
• In immunocompromised patients (which includes those with chronic liver disease), consider other infectious causes including herpes simplex virus and cytomegalovirus 1, 3

Second-Line: Biphasic Esophagram

• If endoscopy is unrevealing or shows only subtle abnormalities, proceed with biphasic esophagram which has 95% sensitivity for detecting lower esophageal rings and strictures that may be missed on endoscopy 1
• The biphasic technique (combining double-contrast and single-contrast views) provides superior detection of both mucosal lesions and structural abnormalities 1, 2
• Prone single-contrast views are particularly important as lower esophageal rings are 2-3 times more likely to be diagnosed this way compared to upright views 1

Third-Line: High-Resolution Manometry

• If structural causes are excluded, high-resolution manometry is essential to evaluate for esophageal motility disorders including achalasia, diffuse esophageal spasm, or other dysmotility 2, 5
• Videofluoroscopy has 80-89% sensitivity and 79-91% specificity for diagnosing esophageal motility disorders 1, 2
• Barium studies and manometry are complementary—one may reveal abnormalities missed by the other, so both should be considered if initial testing is non-diagnostic 2

Critical Considerations in Chronic Liver Disease

Immunocompromised Status

• Chronic liver disease creates an immunocompromised state that increases risk for persistent or recurrent esophageal candidiasis 3, 6
• Patients with chronic liver disease have impaired cell-mediated immunity predisposing to esophageal mucosal colonization 7, 6
• Evaluate for concomitant oral thrush on physical examination, as this is a risk factor for esophageal candidiasis 3, 6

Esophageal Motility Disorders

• Chronic liver disease patients may have underlying esophageal dysmotility that contributed to the initial candidiasis and now manifests as persistent dysphagia 6
• Esophageal motility disorders (like achalasia and scleroderma) are recognized risk factors for esophageal candidiasis 6

Common Pitfalls to Avoid

• Do not assume dysphagia is simply residual inflammation—structural complications like strictures require endoscopic dilation and can cause severe malnutrition and weight loss if untreated 4
• Do not skip biopsies even with normal-appearing mucosa—eosinophilic esophagitis can be present without obvious endoscopic findings 2
• Do not rely on a single diagnostic test—barium studies may reveal strictures or rings missed on endoscopy, and manometry may show dysmotility not apparent on structural imaging 1, 2
• Do not overlook recurrent candidiasis—in patients with delayed recovery of esophagitis, esophageal candidosis should be suspected and antifungal therapy reconsidered 1

Treatment Considerations Based on Findings

If Esophageal Stricture Identified

• Endoscopic dilation is the primary intervention for strictures complicating esophageal candidiasis 4
• Address underlying immunosuppression and nutritional status, as malnutrition and weight loss commonly occur with strictures 4

If Motility Disorder Identified

• First-line pharmacological therapy includes smooth muscle relaxants, neuromodulators (tricyclic antidepressants or SSRIs), and proton pump inhibitors 2
• For refractory distal esophageal spasm, per-oral endoscopic myotomy (POEM) has >90% success rates 2

If Recurrent Candidiasis

• Fluconazole 200-400 mg daily for 14-21 days is the preferred treatment 3
• Consider long-term suppressive therapy in patients with chronic liver disease and history of esophageal candidiasis, similar to recommendations for AIDS patients 7