What are the causes of esophageal odynophagia triggered by water ingestion?

Esophageal Pain When Drinking Water: Causes and Clinical Approach

Pain on swallowing water (odynophagia) most commonly results from infectious esophagitis (Candida, HSV, CMV), inflammatory conditions (eosinophilic esophagitis, reflux esophagitis, medication-induced injury), or esophageal motility disorders—with the specific etiology determined by immune status, medication history, and associated symptoms. 1

Primary Infectious Causes

Candida esophagitis is the most frequently encountered infectious cause of esophageal odynophagia, presenting with dysphagia and odynophagia alongside characteristic white nummular lesions on endoscopy. 1

• Risk factors include recent antibiotic use, corticosteroids (local or systemic), immunosuppression, malignancy, proton pump inhibitor use, older age, chronic alcohol use, chronic kidney disease, diabetes, and esophageal motility disorders causing stasis. 1
• Diagnosis requires endoscopy with cytobrush or biopsy demonstrating fungal forms. 1
• Treatment is fluconazole 200-400 mg daily for 14-21 days. 1

Herpes simplex virus (HSV) and cytomegalovirus (CMV) are additional infectious causes, though less common than Candida. 1 While more prevalent in immunosuppressed patients, these infections can occur in immunocompetent hosts. 1, 2

Inflammatory and Immune-Mediated Causes

Eosinophilic esophagitis (EoE) presents with esophageal dysfunction symptoms including chest pain and dysphagia, triggered by food or aeroallergens inducing a type-2 allergic response. 1

• Endoscopic findings include edema, rings, exudates, linear furrows, and strictures—though the esophagus may appear normal. 1
• Multiple biopsies from 2 or more levels are required as inflammation is patchy. 1
• Treatment involves topical corticosteroids or dietary elimination. 3

Lymphocytic esophagitis affects predominantly women over age 60 and presents with dysphagia similar to EoE. 1 Treatment includes proton pump inhibitors or swallowed topical corticosteroids. 1

Medication-induced esophagitis should be suspected with history of nonsteroidal anti-inflammatory agents, potassium supplements, iron, or bisphosphonates. 1, 4

Gastroesophageal Reflux Disease (GERD)

GERD is the most likely cause of recurring unexplained esophageal chest pain, presenting as squeezing or burning pain lasting minutes to hours, often occurring after meals or at night. 1

• Pain may worsen with stress and can resolve with antacids. 1
• Peptic esophagitis from GERD affects 8-19% of adults with endoscopic findings. 4

Esophageal Motility Disorders

Achalasia and other motility disorders (diffuse esophageal spasm, nutcracker esophagus) present with squeezing retrosternal pain or spasm, often accompanied by dysphagia to both solids and liquids from onset. 1, 5

• Recent evidence supports infectious and/or allergy-associated etiologies for secondary achalasia—query for recent COVID infections, Chagas disease risk, and eosinophilic disease symptoms. 1
• Interestingly, cold water increases lower esophageal sphincter pressure and prolongs esophageal body contraction duration in achalasia patients, exacerbating symptoms, while hot water decreases sphincter pressure and relieves symptoms. 6

Systemic Disease Manifestations

Rheumatologic diseases (systemic sclerosis, mixed connective tissue disease, systemic lupus erythematosus, Sjögren's disease) cause esophageal symptoms through muscle layer involvement resulting in dysmotility and lower esophageal sphincter incompetence. 1

Crohn's disease can involve the esophagus with inflammatory, stricturing, or fistulizing changes, typically occurring with active intestinal disease. 1

Dermatologic diseases (lichen planus, bullous disorders) cause dysphagia through visible esophageal mucosal involvement. 1, 3

Diagnostic Algorithm

For acute presentation with odynophagia:

1. Assess immune status immediately: HIV status, immunosuppressive medications, malignancy, diabetes, recent antibiotics, corticosteroid use. 1, 2

2. Examine for oral thrush: Presence strongly suggests Candida esophagitis. 1

3. Identify red flag symptoms requiring urgent endoscopy (within 2 weeks): dysphagia, odynophagia, gastrointestinal bleeding, unexplained iron deficiency anemia, weight loss, recurrent vomiting. 1

4. For immunocompromised patients with thrush and odynophagia: Consider empiric fluconazole 200-400 mg daily. 1

5. For immunocompetent patients without thrush: Proceed directly to upper endoscopy with biopsies and cultures. 1

6. If endoscopy is normal and symptoms persist: Consider esophageal function testing, pH monitoring, and high-resolution manometry to exclude motility disorders. 1, 5

Critical Clinical Pitfalls

• Do not assume single pathology in immunocompromised patients—concurrent infections are common and parsimony of diagnosis does not apply. 2
• Do not overlook pill esophagitis—specifically query about NSAIDs, potassium, iron, and bisphosphonates. 1, 4
• Do not dismiss symptoms in patients with normal endoscopy—motility disorders and functional abnormalities require specialized testing. 1
• Do not delay endoscopy in patients with alarm symptoms—esophageal strictures and malignancies require urgent evaluation. 1