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; Can do GI cocktail combination (maalox, benadryl, lidocaine) swish and swallowx 3 days.
Prevention: take culprit meds w/ 8 oz water and sit upright for 30 mins after.
Diagnosis: consider empiric fluconazole trial (improvement by 3-5 days). If refractory, EGD, biopsy, culture
Treatment: fluconazole 400mg PO/IV day 1, then 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 400mg PO five times daily x14-21 days (immunocompromised) acyclovir 200mg PO five times daily or 400mg PO tid x 7-10 days (immunocompetent)
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 q2-3 years recommended to monitor for complications (esophageal stricture, SCC)
Ingestion is often intentional, consider psych eval if appropriate
