What is the appropriate treatment for esophagitis?

Treatment of Esophagitis

For erosive esophagitis (GERD-related), initiate proton pump inhibitor (PPI) therapy as first-line treatment and continue long-term daily maintenance therapy after healing to prevent recurrence; for eosinophilic esophagitis (EoE), start with either PPIs or topical corticosteroids as first-line therapy, with mandatory endoscopic reassessment while on treatment to confirm histological response. 1, 2

Erosive Esophagitis (GERD-Related)

Initial Treatment

• Start with standard-dose PPI therapy (e.g., omeprazole 20 mg twice daily or equivalent) for 8 weeks, which achieves healing rates exceeding 80% in most patients 1, 3
• PPIs are superior to H2-receptor antagonists for both healing mucosal breaks and relieving symptoms 3, 4

Maintenance Therapy

• Long-term daily PPI therapy is mandatory for patients with healed erosive esophagitis, as recurrence rates are extremely high (approaching 80-90%) when PPIs are discontinued 1
• Do NOT use on-demand or intermittent PPI dosing in patients with documented erosive esophagitis—continuous therapy is required to prevent recurrence of erosive disease 1, 5
• On-demand therapy may only be appropriate for endoscopy-negative reflux disease (NERD), not erosive esophagitis 5

PPI-Refractory Cases

• For patients not responding to standard-dose PPI, consider: 6, 7
  • Doubling the PPI dose (divided twice daily before meals)
  • Switching to a different PPI
  • Changing administration timing (before meals rather than after)
  • Evaluating for non-acid reflux with pH-impedance monitoring 6

Critical Pitfall

Never discontinue or reduce to on-demand therapy in patients with a history of erosive esophagitis—this is the most common management error, as recurrence rates of erosive disease are unacceptably high compared to continuous therapy. 1

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Eosinophilic Esophagitis (EoE)

First-Line Treatment Options

Option 1: Proton Pump Inhibitors

• Start with PPI therapy (omeprazole 20 mg twice daily) for 8-12 weeks as initial treatment 2, 8
• PPIs are recommended due to low cost, excellent safety profile, convenience, and substantial efficacy 1, 2
• Recent evidence demonstrates that PPI-responsive EoE and classic EoE are indistinguishable by symptoms, demographics, endoscopic findings, histology, and molecular transcriptome 8
• The PPI trial should be viewed as a potential therapy, not a diagnostic tool to exclude EoE 8

Option 2: Topical Corticosteroids

• Topical corticosteroids (swallowed fluticasone or budesonide) are highly effective for inducing both histological and clinical remission 8, 2
• The American Gastroenterological Association gives topical steroids the only "strong recommendation" among EoE therapies 8
• Use as second-line therapy if PPIs fail, or as first-line in patients preferring to avoid long-term PPI therapy 2

Mandatory Endoscopic Reassessment

• Repeat endoscopy with biopsy after 8-12 weeks of treatment is essential, as symptoms do NOT correlate with histological activity 8, 1, 2
• Approximately 41% of patients report symptomatic improvement without true histologic remission, risking ongoing inflammation and fibrosis 1
• Target histological threshold: <15 eosinophils per high-power field 8

Dietary Therapy

• Six-food elimination diet (SFED) achieves 72-79% histological remission but has lower compliance due to restrictiveness 1, 2
• Two-food elimination diet (TFED) (milk + wheat) achieves 43% remission with better patient acceptance 1
• Four-food elimination diet (FFED) achieves 60% remission as a middle-ground approach 1
• All elimination diets require supervision by an experienced dietitian to prevent nutritional deficiencies and monitor growth in children 1
• Allergy testing (skin prick, IgE, patch testing) has limited predictive value (~45.5% efficacy) and should NOT guide food elimination 1

Treatment of Fibrostenotic Disease

• Endoscopic dilation (balloon or bougie) is effective and safe for improving dysphagia in patients with strictures 1, 2
• Combine dilation with anti-inflammatory therapy (PPIs or topical steroids) for optimal long-term outcomes 2

Maintenance Therapy

• Long-term maintenance treatment is required after achieving histological response, as relapse rates are high after withdrawal 1, 2
• Continue either PPIs or topical corticosteroids indefinitely to prevent recurrent dysphagia, food impaction, and stricture formation 1

Critical Pitfall

Do not assume symptom resolution equals histological healing—endoscopic biopsy assessment is mandatory, as persistent eosinophilic inflammation continues despite symptom improvement in a substantial proportion of patients. 8, 1

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Infectious Esophagitis

Candidal Esophagitis

• Systemic antifungal therapy is first-line treatment 1
• Use fluconazole or itraconazole solution for 14-21 days 1
• HIV-positive patients with esophageal symptoms may be treated empirically with antifungal therapy without initial endoscopy 1

Herpes Simplex or CMV Esophagitis

• Patients with radiographically diagnosed herpes esophagitis may be treated with antiviral agents without endoscopic evaluation 1
• Endoscopy is warranted for patients with giant esophageal ulcers to differentiate cytomegalovirus from HIV ulcers 1

When to Perform Endoscopy

• Severe symptoms at presentation or persistent symptoms despite empiric therapy require endoscopy for specimen acquisition (histology, cytology, immunostaining, culture) 1