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Esophageal Ulcer

Esophageal ulcer is characterized by mucosal damage of the esophagus, often developing as a result of acid reflux in gastroesophageal reflux disease (GERD) or severe and sustained esophagitis.


Presentation

Esophageal ulcer induced by GERD and certain drugs presents both esophageal and gastric symptoms. The intermittent reflux of gastric contents produces discomfort in swallowing resulting in dysphagia, odynophagia and ultimately weight loss [13]. The reflux of acid is characterized by pain behind the sternum and heartburn [12]. A common clinical feature of esophageal ulcer caused by esophageal tuberculosis is hematemesis which produces lesions in the esophagus. 

Camping
  • A cAMP analog (Sp-cAMP) mimicked, whereas an inhibitor of cAMP-dependent protein kinase A (Rp-cAMP) blocked, these effects of misoprostol.[ncbi.nlm.nih.gov]
  • Paull AP, Trier JS, Dalton MD, Camp RC, Loeb P, Goyal RK. The histologic spectrum of Barrett's esophagus. N Engl J Med 1976;295:476-480. 16.[hon.ch]
Reiter's Syndrome
  • A case like this of Reiter's syndrome with esophageal involvement has not been reported before.[ncbi.nlm.nih.gov]
Arm Pain
  • A 50-year-old woman with lumbago, dysphagia, and left arm pain was presented. Upper endoscopical examination was performed. There was an exudate-covered ulcer in the distal esophagus, located at 30-32 cm from the incisors, covering the whole mucosa.[ncbi.nlm.nih.gov]
Odynophagia
  • Odynophagia, retrosternal chest pain and dysphagia were the usual presenting symptoms. The typical endoscopic finding was that of discrete ulcers in the mid-esophagus.[ncbi.nlm.nih.gov]
  • A young, former homosexual, and narcotics-abusing male patient developed malaise, fever, lymphadenopathy, esophageal candidiasis, lymphopenia, and anergy progressing to severe odynophagia and a weight loss of 60 lb.[ncbi.nlm.nih.gov]
  • Many organisms have been implicated in the pathogenesis of dysphagia and odynophagia. We describe a unique presentation of actinomyces esophageal infection in two homosexual male patients with AIDS and biopsy proven CMV esophagitis.[ncbi.nlm.nih.gov]
  • Odynophagia was the main symptom but may not be the presenting symptom. The diagnosis was easily confirmed by endoscopy. Single-contrast barium study was not sensitive for the demonstration of the esophageal ulcers.[ncbi.nlm.nih.gov]
  • A 36-year-old man with a 5-year history of untreated human immunodeficiency virus (HIV) infection had odynophagia for 14 days.[ncbi.nlm.nih.gov]
Hematemesis
  • A 28-year-old male uremic patient had a sudden onset of hematemesis on hemodialysis. Urgent endoscopy revealed an acute mucosal lesion with bleeding at the upper and middle third esophagus. It was demonstrated by esophageal biopsy.[ncbi.nlm.nih.gov]
  • A 66-year-old man suffered massive hematemesis; he was diagnosed as having an aortoesophageal fistula due to an esophageal ulcer after examination by upper endoscopy, computed tomography, and angiography.[ncbi.nlm.nih.gov]
  • The most common agonal symptoms were hematemesis (41.8%), abdominal pain (25.6%), melaena (22.1%), and dyspnea (17.4%). Twenty (23.3%) patients were found dead at home.[ncbi.nlm.nih.gov]
  • Left: 70 year-old woman with hematemesis. Endoscopy demonstrated a long, deep benign distal esophageal ulcer. Right: 88 year-old woman with hematemesis.[endoatlas.com]
  • A common clinical feature of esophageal ulcer caused by esophageal tuberculosis is hematemesis which produces lesions in the esophagus.[symptoma.com]
Melena
  • This type of stool condition is called melena. Should your esophageal bleeding be rapid then the blood discharge in the stools will be a bright red color.[streetdirectory.com]
  • A 26 year-old male kidney transplant recipient was referred with a complaint of melena. Upper gastrointestinal endoscopy showed a huge esophageal ulcer in the anastomosis site of the esophagogastrostomy.[synapse.koreamed.org]
  • Furthermore, bleeding esophageal ulcers may be associated with melena. In the long esophageal ulcers, especially against the background of lack of treatment, the patient begins to lose weight comes cachexia.[carbohealth.com]
  • Patients with bleeding ulcers may report passage of black tarry stools (melena), weakness , a sense of light-headedness or ay even pass out upon standing ( orthostatic hypotension or syncope ) and vomiting blood (hematemesis).[medicinenet.com]
Dyspepsia
  • Right: 83 year-old man with dysphagia but no odynophagia, pyrosis or dyspepsia. Endoscopy revealed twin "kissing" ulcers just above a lower esophageal stricture through which the endoscope would not pass until after gentle balloon dilation.[endoatlas.com]
  • Clinically, the disease is manifested and psevdostenokarditicheskimi retrosternal pain, dysphagia and dyspepsia amoxil-info.net .[carbohealth.com]
  • Contrary to the first and second generation biphosphonates (etidronate, chlodronate), that were associated with pronounced and frequent adverse effects (vomiting, diarrhea, dyspepsia), alendronate is apparently much more tolerable. 2 In addition, its[scielo.br]
Bulimia
  • Moreover, forced vomiting that ensues repeated expulsion of gastric contents in patients with bulimia nervosa periodically exposes the esophageal mucosa to gastric acid causing open sores.[symptoma.com]
Chest Pain
  • Odynophagia, retrosternal chest pain and dysphagia were the usual presenting symptoms. The typical endoscopic finding was that of discrete ulcers in the mid-esophagus.[ncbi.nlm.nih.gov]
  • The next morning I woke up with severe chest pains. I took a bunch of antacids, etc and nothing helped. After 3 hours my girlfriend made me go to the Urgent Care. I thought it was my heart for sure. They did an EKG and said it wasn't my heart.[justanswer.com]
  • Ulcer of the esophagus is inherent in a particular characteristic for her symptom: chest pain, dysphagia, heartburn, vomiting, emaciation.[carbohealth.com]
  • The yellow tags represent the ablation sites where the patient complained of chest pain, and the energy application was immediately terminated. C , Endoscopy performed on postablation day 5.[circ.ahajournals.org]
  • Severe chest pain is a symptom of a heart attack; seek immediate medical help. Heartburn that is frequent and interferes with life is called gastroesophageal reflux disease (GERD).[wellstar.org]
Retrosternal Chest Pain
  • Odynophagia, retrosternal chest pain and dysphagia were the usual presenting symptoms. The typical endoscopic finding was that of discrete ulcers in the mid-esophagus.[ncbi.nlm.nih.gov]
Cardiomegaly
  • Although esophageal compression due to cardiomegaly may be a risk factor of drug-induced esophageal injuries (DIEIs), the causal relationship between the two conditions has not been fully demonstrated.[ncbi.nlm.nih.gov]

Workup

Diagnosis is based on evaluation of signs and symptoms, physical assessment and an X-ray imaging to obtain an esophagram. Barium swallow is typically used to identify anatomic abnormalities of the esophagus [14]. Esophagogastroduodenoscopy (EGD) is used to perform endoscopic evaluation of the esophagus and identify the cause of an esophageal ulcer. Suspected cases of infectious esophagitis are confirmed by histopathological study following tissue biopsy and blood cultures. In the presence of psychiatric illnesses associated with severe depression, psychiatric evaluation is needed [15]. 

Anergy
  • A young, former homosexual, and narcotics-abusing male patient developed malaise, fever, lymphadenopathy, esophageal candidiasis, lymphopenia, and anergy progressing to severe odynophagia and a weight loss of 60 lb.[ncbi.nlm.nih.gov]
Esophageal Motility Disorder
  • motility disorders esophageal neoplasm very rare except for papilloma and fibropapilloma; causes chronic esophageal obstruction. esophageal obstruction acute obstruction is manifested by inability to swallow, regurgitation of saliva, food and water through[medical-dictionary.thefreedictionary.com]
  • Physical obstruction or disorders that interfere with motor function ( esophageal motility disorders ) can affect the system. The patient’s history suggests the diagnosis almost 80% of the time.[merck.com]
  • Reported complications of pneumonectomy include mediastinal shift with herniation of the remaining lung, cardiac herniation, cardiac arrhythmias, bronchopleural fistula, esophageal motility disorders, and development of scoliosis [ 9 – 11 ].[bmcpediatr.biomedcentral.com]
HLA-B27
  • The patient was HLA-B27 negative. Radiographic and endoscopic examinations of the upper gastrointestinal (GI) tract showed multiple round or irregularly shaped small ulcers in the middle and distal portion of the esophagus.[ncbi.nlm.nih.gov]

Treatment

Identification of the definite cause of esophageal ulcer is of utmost importance as management is based on treating the cause. Severe cases of esophageal injury are managed by intubation with nasogastric tube, administration of intravenous fluids, chemoprophylaxis with antibiotics, pain relief with analgesics and treating the ulcer with H2 receptor anatagonists and PPIs. 

Treatment of esophageal ulcer caused by GERD is aimed at symptomatic management, promoting persitalsis and controlling acid secretion. Temporary relief from symptoms is achieved by the use of H2 receptor antagonists. The commonly used H2 receptor blockers are cimetidine, ranidtidine, famotidine and nizatidine. However, long-term resolution is achieved by the use of PPIs which directly inhibit acid secretion from gastric parietal cells by blocking proton pumps. Available PPIs used to treat GERD include omeprazole, esomeprazole, lasoprazole, pantoprazole and rabeprazole. Additionally, esophageal clearance can be promoted by prokinetics that increase motility of the gastrointestinal tract. Cisapride and metoclopramide are the commonly employed prokinetics to promote esophageal peristalsis.

If GERD occurs secondary to Helicobacter pylori infection, the standard treatment is followed which is based on triple therapy with a PPI and two antibiotics. The standard treatment regimens available for eradication of Helicobacter pylori include administration of ompeprazole, amoxicillin and clarithromycin (OAC) for 10 days, bismuth subsaclicylate, metronidazole and tetracyline (BMT) for 14 days and lansoprazole, amoxicillin and clarithromycin (LAC) for 10-14 days [16].

Treatment of drug-induced esophageal ulcer includes discontinuation of the drug causing mucosal damage and administration of PPIs and gastroprotective agents [17]. Esophageal ulcer occurring as a result of esophageal tuberculosis requires standard antitubercular treatment based on IREP therapy (Isoniazid, rifampicin, ethambutol and pyrazindamide). The duration of treatment varies from 6-9 months, depending on patient's condition. 

Antimicrobial agents are used to treat mucosal damage caused by infectious esophagitis. Infection caused by cytomegalovirus is treated with ganciclovir whereas fluconazole is the preferred choice in treatment of esophageal candidiasis. HIV infected patients with esophageal ulcer have been found to respond well to antiretroviral therapy. Idiopathic esophageal ulcers are treated with corticosteriods although the risk of developing opportunistic infections is increased due to immunosuppressive effects of steroids. 

Prognosis

Prognosis is good in patients strictly following treatment regimen and maintaining appropriate diet. Disease recurrence after treatment with proton pump inhibitors is common and such patients require maintenance therapy to avoid relapse [11]. A serious complication of GERD with poor prognosis is the development of esophageal adenocarcinoma. However, the risk for developing adenocarcinoma is extremely rare occurring in about 0.1% patients [8].

Etiology

Typical etiologic factors that cause esophageal ulcers comprise preexisting esophageal disorders such as GERD and achalasia, infectious esophagitis and use of certain drugs. Damage to the esophageal mucosa due to any cause can lead to esophageal ulcer formation. The most common cause of mucosal damage is acid reflux that occurs in GERD. The lower esophageal sphincter (LES) which is responsible for preventing the back flow of acid becomes weak in GERD due to which it fails to hinder the acid reflux and consequently exposure of esophageal mucosa to gastric acid causes ulceration. Moreover, forced vomiting that ensues repeated expulsion of gastric contents in patients with bulimia nervosa periodically exposes the esophageal mucosa to gastric acid causing open sores. 

Another common cause is inflammation of the esophagus that occurs from infection. The infections can be viral, bacterial, fungal or parasitic in origin and often emerge in immunocompromised individuals, such as those suffering from acquired immunodeficiency syndrome (AIDS) and diabetes mellitus [3] [4]. Commonly involved causative agents in infectious esophagitis are herpes simplex virus (HSV), human immunodeficiency virus (HIV), candida albicans, cytomegalovirus (CMV) and mycobacterium tuberbulosis. The risk of developing opportunistic infection in the form oroesophageal candidiasis is increased by prolonged and recurrent use of antibiotics and chemotherapeutic agents as their use inhibits the normal protective flora of the esophagus making it prone to be infected by opportunistic pathogens. 

Some drugs adversely affect the esophagus on prolonged contact with the esophageal mucosa or through side effects following systemic absorption. Use of drugs that may weaken LES or alter its tonicity can also cause acid reflux. Drugs that may cause esophageal ulcer include tetracyclines, NSAIDs [5], bisphosphonates, potassium chloride and iron compounds. Chronic consumption of acid rich foods, caffeinated drinks, alcohol and cigarette smoking [13] worsens the condition by destroying the esophageal lining and delaying regeneration of healthy esophageal mucous membrane.

Epidemiology

The reported prevalence rate of esophageal ulcers emerging from GERD has been found to lie between 2%-7% [6] [7]. 

Sex distribution
Age distribution

Pathophysiology

In case of esophageal ulcer induced by GERD, the period of exposure to gastric acid and bile salts largely determines the extent of mucosal erosion. Ulceration is directly related to the number of times gastric contents flow back into the esophagus as the more the episodes of esophageal reflux, more will be the mucosal damage [8]. Apart from this, weakened contractions of the LES causes hindrance in clearing gastric acid from the esophagus which further aggravates the condition. Furthermore, persistent acid reflux coupled with lowered resting tone of upper esophageal sphincter (UES) precipitates laryngopharyngeal symptoms causing cough, sore throat and throat clearing [9]. The natural resistance of mucosal epithelium against gastric contents also indicates the severity of damage. Inability of the damaged mucosa to undergo regeneration and healing further worsens the ulceration. 

One complication that follows GERD due to prolonged aspiration of gastric reflux contents is reflux-induced asthma and is characterized by vasovagal bronchoconstriction. A usual finding in chronic asthmatic patients is asymptomatic gastroesophageal reflux [10]. 

Prevention

Since GERD is the leading cause of esophageal ulcer, controlling acid reflux and gastric hyperacidity helps in preventing the disease. Dietary modification aimed at reducing intake of spicy, acid rich foods and caffeinated beverages and incorporating alkaline foods controls acidity and prevents heart burn. Cigarette smoking, carbonated drinks and alcohol should be avoided in all cases. Regular intake of milk keeps from developing acidity as it a natural antacid

Summary

Esophageal ulcer is the erosion of esophageal mucosa that causes the formation of an open sore. Gastroesophageal reflux disease (GERD) is the most common cause of esophageal ulcer. GERD is the flow of acid rich gastric contents back into the esophagus. Since the esophageal mucosa lacks a protective lining against gastric contents, the acid reflux damages the esophageal mucous membrane causing an esophageal ulcer. Other causes of esophageal ulcer are esophagitis and use of certain anti-inflammatory medications.

Prolonged and recurrent ulceration due to GERD can result in metaplastic change in the mucosal lining of the esophagus, a condition referred to as Barrett esophagus. Barrett esophagus is presented with symptoms similar to those of GERD such as heart burn, retrosternal pain, hematemesis and dysphagia [1] [2]. 

An esophageal ulcer possesses a high risk of recurrence after treatment. In such cases, aggressive treatment is required following standard regimen of proton pump inhibitors (PPI). Diagnosis is established on evaluation of patient's history, assessment of symptoms, physical examination and certain tests. Usually, barium swallow and upper GI endoscopy are utilized to identify the ulcer. Other tests include tissue biopsy and blood culture. 

Treatment is aimed at resolution of the underlying cause and control of symptoms to relief discomfort. PPIs are the standard agents used to treat GERD while infectious esophagitis may require intervention with antimicrobial agents. 

Patient Information

As the name indicates, esophageal ulcer is the formation of an ulcer or open sore inside esophagus. The esophagus is a long hollow tube that provides passage of food from the throat to the stomach. Several causes of esophageal ulcer have been identified. The most common cause is gastroesophageal reflux disease (GERD). The disease is characterized by reverse flow of stomach contents into the esophagus. The continuous exposure of acid in stomach contents with the inner lining of esophagus damages it, causing esophageal ulcer. Infection caused by bacteria, virus, fungus or parasite can also provoke esophageal ulcer. Common disease causing organisms that have been identified are herpes simplex virus (HSV), cytomegalovirus (CMV) and candida albicans. Esophageal ulcer can also result from side effects of certain medications. In some cases, excessive cigarette smoking, intake of alcohol, colas and spicy food can also damage the esophagus and cause ulcers. 

Symptoms that commonly occur with esophageal ulcers are heartburn, chest pain, pain and difficulty in swallowing food, loss of appetite, nausea, vomiting and weight loss

Diagnosis is based on disease history, evaluation of signs and symptoms, physical examination, X-rays, endoscopy and blood tests. X-ray of the esophagus is obtained by barium swallow method. In this procedure, the patient is instructed to drink a solution of barium after which X-ray is obtained to show a clear image. Another test used to establish accurate diagnosis is endoscopy of the upper digestive tract. An endoscope is inserted in the patient's mouth through which internal structures of esophagus are visualized to see the presence of ulceration on the inner lining. In some cases, tissue biopsy is performed along with blood tests to identify any suspected case of infection. 

Treatment depends on the cause of ulceration and disease severeness. Medications used to reduce production of stomach acid and antibiotics to treat infectious cause are used. The standard medications used in GERD are proton pump inhibitors (PPIs). Patients are advised to avoid spicy and acid rich foods and intake of medications that may cause acidity. Medicines that must be avoided include aspirin, ibuprofen, naproxen, diclofenace sodium, iron and potassium. 

References

Article

  1. Sharifi A, Dowlatshahi S, Moradi TH, Fatemah S, Omid S. The Prevalence, Risk Factors, and Clinical Correlates of Erosive Esophagitis and Barrett's Esophagus in Iranian Patients with Reflux Symptoms. Gastroenterol Res Pract. 2014;696294.
  2. Higuchi D, Sugawa C, Shah SH, et al. Etiology, treatment, and outcome of esophageal ulcers: a 10-year experience in an urban emergency hospital.J Gastrointest Surg. 2003;7(7):836-842.
  3. Wilcox CM, Schwartz DA. Comparison of two corticosteroid regimens for the treatment of HIV-associated idiopathic esophageal ulcer. Am J Gastroenterol. 1994;89:2163–2167.
  4. Wilcox CM, Schwartz DA, Clark KS. Esophageal ulceration in human immunodeficiency virus infection. Causes, response to therapy, and long-term outcome. Ann Intern Med. 1995;122:143–149  
  5. Eng J, Sabanathan S. Drug-induced esophagitis. Am J Gastroenterol. 1991;86:1127–1133.
  6. Vito D, Lidia D, Ermira Z, et al. A case of oesophageal ulcer developed after taking homeopathic pill in a young woman. World J Gastroenterol. 2007;13(14): 2132-2134.
  7. Splechler SJ. Complications of gastroesophageal reflux disease. In Castell DO, ed. The Esophagus. New York: Little Brown;1995;533–545.   
  8. Richter J. Severe reflux esophagitis. Gastrointest Endosc Clin. North Am. 1994;4:677–698.
  9. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1383-1391.
  10. Ronkainen J, Aro P, Storskrubb T, et al. Prevalence of Barrett's esophagus in the general population: an endoscopic study. Gastroenterology. 2005;129:1825-1831.
  11. Dent J, El-Serag HB, Wallander MA, et al. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2005;54:710-717.
  12. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108:308-328.
  13. Patrick L. Gastroesophageal reflux disease (GERD): a review of conventional and alternative treatments. Altern Med Rev. 2011;16(2):116-133.
  14. Srilatha PS, Suvarna N, Gupta A. Esophageal ulcer in a HIV-seropositive patient co-infected by herpes simplex and cytomegalovirus. Indian J Pathol Microbiol. 2011;54(1):219-220
  15. Levine M S, Rubesin S E. Radiologic investigation of dysphagia. Am J Roentgenol. 1990;154(6):1157-1163.
  16. Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. 2007;76(7):1005-1012.
  17. Dag M, Abidin OZ, Akin I, et al. Drug-induced esophageal ulcers: Case series and the review of the literature. Turk J Gastroenterol. 2014;25(2):180-184.

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Last updated: 2019-07-11 21:39