Diagnostic Considerations
Always consider the possibility of a systemic illness causing the esophageal manifestations (eg, acquired immunodeficiency syndrome [AIDS], scleroderma, systemic lupus erythematosus (SLE), pemphigus). Always consider cardiac causes of chest discomfort and treat appropriately. If the diagnosis is unclear, admission for further evaluation is suggested. Do not misdiagnose cardiac chest pain as esophageal pain. Pain can be similar, particularly in elderly patients and women.
See Pediatric Esophagitis for complete information on this topic.
Conditions that may mimic symptoms of esophagitis include the following:
-
Coronary artery disease
-
Pericarditis
-
Aortic aneurysm
-
Nonulcer reflux disease
-
Functional dyspepsia
-
Stricture
Diagnosis of Candida esophagitis
Glycogenic acanthosis, reflux esophagitis, herpes esophagitis, and superficial spreading carcinoma may produce findings similar to those seen in Candida esophagitis. However, patients with glycogenic acanthosis are almost always older individuals who have no esophageal symptoms, and the mucosal nodules of glycogenic acanthosis tend to have a more rounded appearance, whereas the plaques of candidiasis are more linear.
Reflux esophagitis may also manifest as a nodular mucosa, but the nodules tend to be more poorly defined than those in candidiasis, and they are always contiguous with the gastroesophageal junction.
Occasionally, herpes esophagitis manifests as multiple plaquelike lesions in the esophagus, but this infection is more commonly associated with small superficial ulcers (see below). Superficial spreading carcinoma may also manifest as a nodular mucosa, but the nodules tend to have poorly defined borders, producing a confluent area of disease.
Undissolved effervescent particles and debris in the esophagus can be mistaken for the plaques of candidiasis. Thus, if infectious esophagitis is suggested clinically, a double-contrast study should initially be performed without the use of effervescent granules.
Diagnosis of herpes esophagitis
In the appropriate clinical setting, discrete superficial ulcers in the upper or mid esophagus without associated plaques should be highly suggestive of herpes esophagitis. In contrast, ulceration in Candida esophagitis almost invariably occurs on a background of extensive plaque formation. Candida and herpes esophagitis can often be diagnosed on double-contrast studies, obviating endoscopy. However, if radiographic findings are equivocal or if the response to treatment is inadequate, endoscopy should be performed for a more definitive diagnosis.
Other causes of small superficial ulcers in the upper or middle esophagus include drug-induced esophagitis and Crohn disease. However, these entities usually can be differentiated from infectious esophagitis on the basis of the clinical history.
Diagnosis of cytomegalovirus esophagitis
Because herpetic ulcers rarely become as large as those of infectious esophagitis, the presence of one or more giant ulcers suggests the possibility of cytomegalovirus (CMV) esophagitis in patients with AIDS. However, in patients who are positive for human immunodeficiency virus (HIV), giant esophageal ulcers can also be caused by HIV (see below).
Other causes of giant esophageal ulcers include nasogastric intubation; endoscopic sclerotherapy; caustic injuries; and oral medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), potassium chloride, and quinidine. However, the correct diagnosis can almost always be suggested on the basis of the clinical history.
See Cytomegalovirus Esophagitis for complete information on this topic.
Diagnosis of HIV esophagitis
Because most HIV ulcers are indistinguishable from CMV ulcers on the basis of the clinical and radiographic criteria, CMV esophagitis must be excluded by means of endoscopy before a diagnosis of HIV esophagitis can be established. Biopsy specimens, brushings, and/or viral cultures from the esophagus may be needed.
Differentiating between these infections is essential because most cases of HIV esophagitis dramatically respond to treatment with oral steroids, whereas CMV esophagitis is treated with relatively toxic antiviral agents such as ganciclovir (see Cytomegalovirus Esophagitis). Endoscopy is required for a definitive diagnosis before patients are treated.
Diagnosis of tuberculous esophagitis
Erosion of caseating nodes into the esophagus may result in the development of longitudinal or transverse sinus tracts or esophageal-airway fistulas. Similar tracts and fistulas may be seen in patients with radiation esophagitis, Crohn disease, trauma, or esophageal cancer. However, in these patients, the clinical history usually suggests the correct diagnosis.
Intrinsic tuberculosis is extremely rare and is characterized by mucosal plaques, ulcers, strictures, and fistulas. The development of dysphagia, coughing, or choking during swallowing suggests the possibility of esophageal involvement or fistula formation in a patient with tuberculosis.
Diagnosis of eosinophilic esophagitis
A noninfectious form of esophagitis that may require differentiation from infectious esophagitis is eosinophilic esophagitis. [52] The majority of patients with this disorder present with intermittent difficulty in swallowing solid food. On barium studies, eosinophilic esophagitis typically produces a series of concentric rings in the esophagus.
In 2013, the American College of Gastroenterology issued guidelines for the diagnosis and management of eosinophilic esophagitis. [53] Diagnostic recommendations include the following:
-
The underlying cause of esophageal eosinophilia should be identified
-
Eosinophilic esophagitis is defined by symptoms, histology, and treatment response
-
The distal and proximal esophagus should be biopsied, as should the antrum and/or duodenum, in all pediatric patients, as well as in adult patients with gastric or small intestinal symptoms or endoscopic abnormalities
Differential Diagnoses
-
Esophagitis. Location of fungal and viral infections in ulcers.
-
Peptic esophagitis. A rapid urease test (RUT) was performed on the esophageal biopsy sample. The result was positive for Helicobacter pylori.
-
Corrosive esophagitis. This is a vinegar-induced esophageal burn. The patient had a fish bone in her throat. She ingested vinegar in an attempt to dissolve the fish bone but to no avail; this led to corrosive esophagitis.
-
Infectious esophagitis. Candida esophagitis. Double-contrast esophagram shows linear plaquelike lesions in the esophagus, with normal intervening mucosa.
-
Infectious esophagitis. Two examples of advanced Candida esophagitis demonstrate a shaggy esophagus. In both images, the double-contrast esophagram shows a grossly irregular esophageal contour due to innumerable plaques and pseudomembranes, with the trapping of barium between lesions. Patients with this fulminant form of esophageal candidiasis are almost always found to have acquired immunodeficiency syndrome (AIDS).
-
Infectious esophagitis. Candida esophagitis with a foamy esophagus. This patient has a dilated esophagus with beaklike narrowing (arrow) at the gastroesophageal junction as a result of long-standing achalasia. Innumerable tiny bubbles are layering out in the barium column due to infection by the yeast form of candidiasis.
-
Infectious esophagitis. Herpes esophagitis. Double-contrast esophagram shows small, discrete ulcers (arrows) in the mid esophagus on a normal background mucosa. Note the radiolucent mounds of edema surrounding the ulcers. In the appropriate clinical setting, this appearance is highly suggestive of herpes esophagitis, since ulceration in candidiasis almost always occurs on a background of diffuse plaque formation.
-
Infectious esophagitis. Cytomegalovirus esophagitis in a patient with acquired immunodeficiency syndrome (AIDS). Double-contrast esophagram shows a large, flat ulcer in profile (large arrows) in the mid esophagus with a cluster of small satellite ulcers (small arrows). Because HIV esophagitis may produce identical radiographic findings, endoscopy is required to confirm the presence of cytomegalovirus before patients are treated.
-
Infectious esophagitis. Two examples of giant human immunodeficiency virus (HIV) esophageal ulcers (arrows) in patients with acquired immunodeficiency syndrome (AIDS). In A, the ulcer is seen in profile, whereas in B, the ulcer is seen en face. Endoscopy is required to exclude cytomegalovirus as the cause of this finding before treating patients.
