Esophagitis with Case

00:00 So now that we've gone through some of those tests, let's talk about our first case.

00:04 We have a 44-year-old man with HIV who presents to urgent care complaining of painful swallowing with both liquids and solids.

00:12 He otherwise feels well. He takes no medications.

00:15 He stopped taking his antiretroviral medications two years ago after he moved to a new city and has not yet established with a new primary care doctor.

00:24 On exam, vitals are normal, oropharynx and abdominal exam is unremarkable.

00:29 And his upper endoscopy findings are shown here.

00:33 So what is the best next step in management? So let's identify some key features in this case. He has odynophagia or pain with swallowing.

00:42 In addition, he's a patient with HIV off his antiretroviral therapy. He has a normal exam otherwise.

00:50 And on endoscopy he has these white raised, kind of thick looking plaques throughout his esophagus.

00:57 So the most likely diagnosis here is esophageal thrush or Candida albicans.

01:05 We'll talk a bit more about that next.

01:08 So there are three main types of esophagitis; the first is an infectious esophagitis, the second is pill-induced esophagitis, and the third is eosinophilic esophagitis.

01:19 We'll talk about each three of these in detail.

01:22 So infectious esophagitis can be caused by many organisms.

01:27 One of the most common causes is Candida albicans.

01:30 It can affect both immunocompromised and immunocompetent patients.

01:34 They tend to have a white raised plaques on their endoscopy.

01:38 And treatment is with an antifungal agent like fluconazole.

01:42 Patients may also have infection with Cytomegalovirus or CMV. In general, this usually affects immunocompromised patients.

01:51 They may have large, superficial ulcerations on endoscopy and they should be treated with ganciclovir or valganciclovir.

01:59 Lastly, they may also have herpes simplex virus or HSV.

02:04 This can affect both immunocompromised and immunocompetent patients but tends to mostly affect immunocompromised.

02:11 They may have small, deep ulcerations on their endoscopy And you treat them with acyclovir.

02:17 Our second type of esophagitis is pill-induced esophagitis.

02:23 This is when pills become stuck in the esophagus and cause local erosions.

02:28 Patients will present with pain with swallowing, difficulty swallowing, and may have chest pain.

02:34 Common medications that cause this are basically any pills that are large and difficult to swallow.

02:41 So some common culprits are; bisphosphonates like alendronate, antibiotics such as doxycycline, potassium supplements, and Iron supplements.

02:52 All of these are known to be large pills that commonly cause esophagitis.

02:57 Over here on the right you can see an upper endoscopy that shows stellate erosions that are consistent with pill-induced esophagitis.

03:05 So in general, what you want to do is prevent this from happening.

03:09 In general, you tell patients to drink plenty of water with their medications and avoid lying down for 30 mins after they take their pills.

03:17 Our third type of esophagitis is eosinophilic esophagitis.

03:22 This is a rare condition but it is commonly tested.

03:25 So it is an esophageal squamous mucosal inflammation that results from eosinophils infiltrating the esophageal tissue.

03:34 Some keywords to note for test-taking purposes are; young man with atopy who presents with dysphagia and frequent food impactions.

03:43 It tends to be associated with food allergies, asthma, eczema, and GERD.

03:50 The diagnosis is made by upper endoscopy.

03:55 And the typical features you may see are these longitudinal furrows along the length of the esophagus, some fragile mucosa, you may see what's called a trachealized esophagus; when you begin to see rings around the esophagus much like the appearance of the trachea, and you may see small white plaques that may look like candidiasis.

04:18 This patient should be treated with an eight-week trial of proton pump inhibitor or topical glucocorticoids.

04:26 So now let's return to our case.

04:29 We had a 44-year-old man with HIV off his medications with a normal exam but his endoscopy shows these white raised thick plaques throughout the esophagus.

04:39 So the first step is to make the diagnosis since he's immunocompromised and he has pain with swallowing, you should think about candidiasis.

04:49 And the next step is to treat with oral fluconazole.