Odynophagia

Will Lavercombe

Definition

  • Pain with swallowing, often accompanied by dysphagia and retrosternal discomfort.

Etiology: (PIECE)

  • Pill-induced: antibiotics (tetracyclines), NSAIDs, ART, K-Cl, bisphosphonates
    • Diagnosis: clinical, but EGD may be warranted for persistent(> 1wk) or severe symptoms
    • Rx: discontinue culprit med (or substitute with liquid formulation) and start PPI; Analgesia: Tylenol can be used; NSAIDs should be avoided
    • Prevention: take culprit meds w/ 8 oz water and sit upright for 30 mins after.
  • Infectious:
    • Candida esophagitis: HIV (CD4 < 100), heme malignancies, chemo, antibiotics, steroids
      • Can exist without OP thrush
      • Diagnosis: consider empiric fluconazole trial (improvement by 3-5 days). If refractory, EGD, biopsy, culture
      • Treatment: fluconazole 200-400mg daily x 14-21 days.
    • HSV esophagitis: immunocompromised including transplant recipients
      • Diagnosis: well-circumscribed “volcano-like” ulcers on EGD, biopsy or brushings of ulcer edge; absence of herpes labialis or oropharyngeal ulcers should not preclude diagnosis
      • Rx: acyclovir 5 mg/kg every 8 hours for 7 days or resolution of symptoms in immunocompromised and immunocompetent patients
    • CMV esophagitis: HIV (CD4 < 50 )
      • Diagnosis: EGD-linear/longitudinal ulcers + confirmed pathology. Generally, PCR/viral load not helpful but negative serology may lower suspicion
      • Rx: begin treatment while path is pending- ganciclovir 5mg/kg IV q12h vs foscarnet (if leukopenia, low plts). Change to PO once able to toleratevalganciclovir 900mg BIDx 3-6weeks.
      • Confirmed CMV esophagitis warrants optho eval for CMV retinitis
  • Eosinophilic esophagitis (see section)
  • Caustic: alkali or acid-induced injury (household cleaners, batteries, pool cleaners).

Evaluation

  • ABCs, including fluid resuscitation and intubation if needed. 
  • Rule out life-threatening perforation based on exam (mediastinitis, peritonitis), end organ damage (CBC, CMP, lactate, UDS), and imaging (CT-chest/abdomen w/contrast showing transmural necrosis). 
  • NPO until evaluation is complete to determine the grade of injury.
  • Avoid attempting to reverse ingestion with emetics or neutralizing agents via NG tube.
  • Stress ulcer ppx w/ PPI. Conflicting evidence for steroids. 
  • EGS consult (preemptively start broad abx) if workup is suggestive of urgent intervention. Otherwise, EGD < 24hrs of ingestion to further grade injury.
  • Lower-grade injury: start on liquid and advance to regular diet over 24-48 hours. 
  • Higher-grade injury: needs ICU-level monitoring; start PO intake at 48 hrs, based on tolerability (liquids vs enteral vs TPN).

Additional information

  • Subsequent EGD monitoring for patients with higher graded injuries or developed strictures.
  • Ingestion is often intentional, consider psych eval if appropriate.
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