Esophagitis: Symptoms, Types, Causes and Treatment

Esophagitis refers to inflammation of the esophagus, the muscular tube that connects your throat to your stomach. While it may seem like a straightforward condition, esophagitis encompasses a range of causes, symptoms, and management strategies. Understanding the nuances behind its various forms is vital for timely diagnosis and effective treatment. In this article, we'll explore the key symptoms, types, underlying causes, and the latest treatment approaches for esophagitis, drawing upon up-to-date scientific research.

Symptoms of Esophagitis

Esophagitis can manifest with a wide spectrum of symptoms, which often overlap with other gastrointestinal conditions. Recognizing these signs is crucial, as early detection can significantly improve outcomes and quality of life.

Symptom	Description	Age Group	Source(s)
Dysphagia	Difficulty swallowing	Children & Adults	1 2 3 4 6 7 9 10 19
Heartburn	Burning sensation behind the breastbone	Older children & Adults	1 3 6 7
Chest Pain	Non-cardiac chest pain	Adults	1 3
Vomiting	Nausea and/or vomiting episodes	Children	2 3 5
Food Impaction	Food gets stuck in the esophagus	Older children & Adults	7 9 10
Abdominal Pain	Pain in the upper abdomen	Children	1 3
Feeding Issues	Poor feeding, refusal, or feeding disorder	Young children	3 5
Extraesophageal	Cough, hoarseness, croup, subglottic stenosis	Children	5

Table 1: Key Symptoms

Understanding the Core Symptoms

Dysphagia, or difficulty swallowing, is the hallmark symptom of esophagitis, especially in eosinophilic esophagitis (EoE). Studies show that up to 70% of adults and 39% of children with EoE report dysphagia, often leading to food impaction—where food becomes stuck in the esophagus and requires medical intervention 1 2 3 6 7 9 10 19. In children, symptoms often present differently: vomiting, abdominal pain, and feeding disorders are more common, particularly in younger children, while older children and adults tend to experience heartburn and dysphagia 3.

Heartburn is another frequent symptom, often indistinguishable from gastroesophageal reflux disease (GERD), complicating the diagnostic process 1 3 6 7. Chest pain and epigastric pain can also occur, sometimes mimicking cardiac issues but generally related to esophageal inflammation 1 3.

Age-Related Manifestations

• Young children: More likely to present with vomiting, feeding difficulties, and vague abdominal pain.
• Older children and adults: More likely to report dysphagia, heartburn, chest pain, and food impaction 1 3 6 7 9 10 19.

Extraesophageal Symptoms

Recent research highlights that EoE can sometimes present with respiratory symptoms such as chronic cough, croup, and hoarseness—these may even precede or occur in the absence of classic gastrointestinal symptoms, especially in children 5.

Symptom Severity and Disease Progression

Severity of symptoms can correlate with physical changes in the esophagus, including wall thickening and increased esophageal pressure, which tend to improve with treatment 4. In addition, symptom scores in children (such as the Pediatric Eosinophilic Esophagitis Symptom Score, or PEESS v2.0) correlate well with underlying histologic and molecular changes, especially with features like dysphagia and pain 2.

Types of Esophagitis

Esophagitis is not a single disease, but a collection of disorders with diverse underlying mechanisms and presentations. Differentiating between these types is essential for targeted treatment.

Type	Defining Feature	Key Population	Source(s)
Eosinophilic Esophagitis (EoE)	Eosinophilic inflammation (>15 eos/hpf)	Children & Adults	1 2 3 6 7 8 9 10 14 19
Reflux Esophagitis (GERD)	Acid-induced inflammation	All ages	7 11 12 14
Infectious Esophagitis	Microbial infection	Immunocompromised	13 14
Drug-induced Esophagitis	Medication injury	All ages	14
Radiation Esophagitis	Post-radiation injury	Cancer Patients	13 18
Acute Necrotizing Esophagitis	Severe, blackened esophagus	Critically ill	13

Table 2: Types of Esophagitis

Eosinophilic Esophagitis (EoE)

EoE is a chronic, immune-mediated disease marked by an accumulation of eosinophils in the esophageal lining. It is now recognized as a distinct condition, separate from GERD, and requires both clinical (dysphagia, food impaction) and histological (≥15 eosinophils per high power field) criteria for diagnosis 6 7 9 10. EoE is strongly associated with other atopic diseases such as asthma, allergic rhinitis, and eczema, and its prevalence is rising in both children and adults 1 2 3 8 9 19.

Reflux Esophagitis (GERD-associated)

This is inflammation caused by the backward flow of stomach acid into the esophagus. The resulting damage can range from mild irritation to erosions and, in chronic cases, strictures 7 11 12 14. GERD and EoE can share overlapping symptoms and even histological features, making proper diagnosis crucial 14.

Infectious Esophagitis

This type is most commonly seen in immunocompromised individuals (such as those with HIV/AIDS or cancer). It is caused by pathogens like Candida, herpes simplex virus, or cytomegalovirus 13 14.

Drug-induced Esophagitis

Certain medications, especially when taken without adequate fluids or lying down immediately after swallowing, can cause local injury to the esophagus. Common culprits include some antibiotics, NSAIDs, and bisphosphonates 14.

Radiation and Acute Necrotizing Esophagitis

Radiation therapy for cancers in the chest area may lead to radiation esophagitis, which can be severe and difficult to treat 18. Acute necrotizing esophagitis, sometimes called "black esophagus," is a rare but life-threatening condition often observed in critically ill patients 13.

Causes of Esophagitis

Understanding what triggers esophagitis is key to both prevention and effective management. Causes can range from immune reactions to physical injury.

Cause	Mechanism	Typical Trigger	Source(s)
Allergic/Immune	Eosinophil-driven, Th2 inflammation	Food/environmental allergens	6 7 8 9 10 19
Acid Reflux	Chemical/immune inflammation	GERD, hiatal hernia	7 11 12 14
Infection	Direct mucosal invasion	Candida, HSV, CMV	13 14
Medication	Direct chemical injury	Pills (NSAIDs, antibiotics)	14
Radiation	Cellular damage from ionizing radiation	Cancer therapy	13 18
Ischemia	Loss of blood supply	Shock, severe illness	13

Table 3: Causes of Esophagitis

Allergic and Immune-Mediated Causes (EoE)

EoE develops due to a complex interplay of genetic and environmental factors that trigger an abnormal immune response in the esophagus. The inflammation is driven by T helper type 2 (Th2) immune cells and cytokines (like IL-5 and IL-13), which recruit eosinophils and mast cells to the esophageal lining 8 9. Food antigens (dairy, wheat, eggs, soy) and airborne allergens are common triggers 7 8 9 10. Many patients with EoE also have a history of other allergic disorders 1 3 9.

• Genetic risk: Certain gene variants (e.g., TSLP, CAPN14) increase susceptibility 8 9.
• Environmental factors: Early life antibiotic exposure, atopic family history 10.

Acid Reflux (GERD)

Traditionally, GERD was thought to cause esophagitis via direct caustic injury from stomach acid. However, newer research suggests cytokine-mediated inflammation, where acid and bile salts stimulate esophageal cells to secrete chemokines, recruiting inflammatory cells 11. Chronic GERD can lead to erosive esophagitis, strictures, and Barrett's esophagus 12 14.

Infectious Causes

Immunocompromised patients are at risk for infectious esophagitis, most commonly due to Candida (fungal), herpes simplex virus, or cytomegalovirus. These infections directly invade and damage the esophageal lining 13 14.

Medication-Induced and Physical Injury

Medications can cause local injury when they linger in the esophagus. Pill-induced esophagitis is preventable by taking medications with enough water and avoiding lying down immediately after swallowing pills 14.

Radiation and Ischemic Injury

Radiation therapy can damage esophageal cells, leading to acute or chronic esophagitis 13 18. Acute necrotizing esophagitis may occur in critically ill patients due to ischemia, infection, or chemical injury 13.

Treatment of Esophagitis

Effective management of esophagitis hinges on identifying and addressing its underlying cause. Treatment strategies have evolved rapidly, especially for EoE, with a focus on both symptom relief and long-term disease control.

Approach	Primary Action	Disease Targeted	Source(s)
Proton Pump Inhibitors (PPIs)	Acid suppression	GERD, some EoE cases	6 9 10 19
Topical Corticosteroids	Reduce inflammation	EoE	6 9 10 15 16 17 19
Dietary Therapy	Remove trigger foods	EoE	6 8 9 10 19
Dilation	Widen narrowed esophagus	EoE with strictures, GERD	6 10 19
Antimicrobials	Treat infection	Infectious esophagitis	13 14
Hydrogel Stents	Promote healing	Radiation esophagitis	18

Table 4: Treatment Approaches

Medical Management

Proton Pump Inhibitors (PPIs)

PPIs remain the first-line therapy for reflux esophagitis and are also effective in some patients with EoE, achieving histologic remission in 41.7% of cases 10 19. They reduce gastric acid production, minimizing further injury 6 9 10.

Topical Corticosteroids

Swallowed topical steroids (budesonide, fluticasone) are the cornerstone of EoE treatment. Clinical trials show that these medications can induce histologic and clinical remission in over 60% of patients, with new orodispersible tablets (like budesonide and fluticasone) showing strong efficacy and safety 15 16 17. Maintenance therapy is often required to prevent relapse 16 17.

• Side effects: Oral candidiasis (fungal infection) is the most common, but generally mild and manageable 15 16 17.

Dietary Therapy

Dietary elimination—removing common trigger foods such as dairy, wheat, and eggs—is effective for many EoE patients. Elemental diets (amino acid-based formulas) or empiric elimination diets have shown to reduce inflammation and improve symptoms 8 9 10 19.

Interventional and Supportive Therapies

Esophageal Dilation

In cases of significant esophageal narrowing or strictures (common in long-standing EoE or severe GERD), endoscopic dilation may be necessary to restore swallowing function 6 10 19.

Antimicrobials

For infectious esophagitis, appropriate antiviral, antifungal, or antibiotic therapy is critical 13 14.

Innovative Therapies

For radiation-induced esophagitis, research into hydrogel stents loaded with regenerative matrix materials shows promise in reducing inflammation and promoting healing 18.

Chronic Disease Management

EoE is a chronic condition; long-term maintenance with topical steroids or dietary strategies is often necessary to prevent recurrence and complications like strictures or food impaction 16 19.

Conclusion

Esophagitis is a complex disorder with diverse presentations, underlying mechanisms, and therapeutic challenges. From the allergic-driven inflammation of EoE to acid-induced injury in GERD, a nuanced approach to diagnosis and management is essential for optimal patient outcomes.

Key Takeaways:

• Symptoms: Dysphagia, heartburn, chest pain, vomiting, and food impaction are common; symptoms vary by age and type of esophagitis.
• Types: EoE and reflux (GERD) esophagitis are most common; infectious, drug-induced, radiation, and necrotizing forms also occur.
• Causes: Range from allergic/immune mechanisms (EoE), acid reflux (GERD), infections, medications, to radiation and ischemia.
• Treatments: Include PPIs, topical corticosteroids, dietary modifications, endoscopic dilation, antimicrobials, and novel regenerative therapies.
• Long-term management: Especially for EoE, maintenance therapy is crucial to prevent relapse and complications.

By staying informed about the latest research and tailored treatment strategies, patients and providers can work together to effectively manage esophagitis and improve quality of life.