Definition

• Inflammation of the esophagus typically affecting the esophageal body and gastroesophageal sphincter (lower esophageal sphincter, LES); most commonly due to gastroesophageal reflux (GER) or secondary to vomiting; the cricopharyngeal sphincter (proximal esophageal sphincter) is less commonly affected.
• Varies from mild self-limiting esophagitis to severe ulcerative esophagitis involving the submucosa and muscularis which can result in stricture formation.

Pathophysiology

• Physiologic defense mechanisms protecting the esophagus from inflammation are the esophageal mucosal barrier (stratified squamous epithelium, intracellular tight junctions, mucus gel, surface bicarbonate), the LES, clearance by esophageal motility, and the neutralizing effect of alkaline saliva.
• Disruption of these esophageal defense mechanisms can result in esophageal inflammation with erosion, and/or ulceration.
• Esophagitis can result in impaired esophageal motility and LES incompetence which may result in further GER perpetuating esophagitis and esophageal damage.

Systems Affected

• Gastrointestinal (GI)-esophagus (esophageal body and LES most commonly affected) and in the vomiting patient primary or secondary GI disease.
• Respiratory-with regurgitation aspiration pneumonia may develop and possibly laryngitis, pharyngitis and rhinitis (reflux rhinitis).

Incidence/Prevalence

Unknown-relatively common clinical diagnosis based on the history or clinical circumstances; incidence probably underestimated, as most cases are not definitively diagnosed.

Geographic Distribution

Esophagitis caused by Pythium spp. (typically in states that border the Gulf of Mexico) and rarely Spirocerca lupi (southern states).

Signalment

Signs

Causes

• Most commonly GER secondary to general anesthesia, hiatal hernia, persistent or chronic vomiting, gastrointestinal disease resulting in delayed gastric emptying and malpositioned esophageal tubes.
• Gastroesophageal reflux disease (GERD) secondary to a primary LES abnormality is poorly understood in veterinary patients.
• Esophageal retention of tablets or capsules (doxycycline most common in cats, clindamycin, NSAIDs).
• Esophageal foreign body.
• Infectious agents-pythiosis, Spirocerca lupi, Candida infection secondary to immune-suppression.
• Uncommon causes of esophagitis include esophageal tumors, radiation injury, megaesophagus, vascular ring anomalies and gastrinoma (Zollinger-Ellision syndrome).
• Eosinophilic esophagitis-has emerged as a common cause of esophagitis in children and adults and is one of the most common causes of esophagitis in humans; reported but rare in veterinary patients.
• Idiopathic.

Risk Factors

• Anesthetic premedications, induction agents, and maintenance drugs including all opioid class drugs, glycopyrrolate, atropine, acepromazine, diazepam, xylaxine, propofol, and halogenated anesthetic agents have been associated with decreased LES tone and GER.
• Hiatal hernia-increases risk for gastroesophageal reflux.
• Preanesthetic fasting for prolonged periods ( 24 h) puts patients at greater risk for gastroesophageal reflux and increased gastric acidity.

Differential Diagnosis

• Esophageal foreign body-usually detected by survey radiography or esophagoscopy.
• Esophageal stricture-segmental narrowing revealed by barium contrast radiography or esophagoscopy.
• Oropharyngeal dysphagia-diagnosed by evaluating swallowing of barium under fluoroscopy.
• Hiatal hernia-usually recognized as a gas- or fluid-filled opacity in the caudodorsal thoracic cavity at the level of the esophageal hiatus; contrast studies with fluoroscopy may be required to document a hiatal hernia.
• Megaesophagus-survey radiography usually reveals diffuse dilation of the esophageal body.
• Esophageal diverticula-focal pouches detected by survey or contrast radiography or esophagoscopy.
• Vascular ring anomaly-usually revealed by barium contrast radiography as a focal dilation of the proximal esophageal body.
• Caudal esophageal neoplasia-esophageal mass effect with possible esophageal dilation.

CBC/Biochemistry/Urinalysis

Usually unremarkable; patients with ulcerative esophagitis or aspiration pneumonia may have leukocytosis and neutrophilia.

Imaging

• Survey thoracic radiography-often unremarkable but may reveal mild esophageal dilation or fluid accumulation in the distal esophagus; aspiration pneumonia may be evident in the dependent portions of the lung; potentially dilation of the esophagus cranial to a stricture, an esophageal foreign body, hiatal hernia or an intraluminal or extraluminal mass may be detected.
• Barium contrast esophagram (static images and/or fluoroscopic)-may reveal esophageal dilation with retention of barium in esophagus, strictures, foreign bodies or masses; fluoroscopic studies allow for evaluation of swallowing, esophageal motility, strictures which may not be apparent on a static esophagram, sliding hiatal hernia and GER (the latter two conditions may require abdominal compressions to demonstrate).

Diagnostic Procedures

• Endoscopy and biopsy-most reliable means of diagnosis; mild cases of esophagitis may be endoscopically normal; visual findings of mucosal hyperemia and edema are common and in more severe cases ulceration and active bleeding; in patients with GER changes are usually most apparent in the distal third of the esophagus. Gastroduodenoscopy should also be performed to evaluate for GI causes of vomiting which can be associated with esophagitis.
• Diagnostic quality esophageal biopsies are difficult to obtain endoscopically due to the composition of the esophageal mucosa which has a tough stratified squamous epithelium. Histopathology provides the most definitive evidence of esophagitis; endoscopy and biopsies are usually reserved for cases unresponsive to therapy.
• Most cases of aspiration pneumonia will resolve when treated with supportive care and broad-spectrum antibiotics; endotracheal or transtracheal aspiration and/or bronchoscopy with bronchoalveolar lavage for cytology, and culture and sensitivity testing may be performed in patients not responding to therapy.

Pathologic Findings

• Mucosal squamous hyperplasia or dysplasia with erosions and ulcers and lymphocytic plasmacytic and neutrophilic inflammation more in the acute phase.
• Barrett's esophagus (squamous metaplasia associated with chronic GERD which can lead to dysplasia and esophageal cancer in humans) has been reported in cats.

Appropriate Health Care

Mildly affected animals can be managed as outpatients; those with more severe esophagitis (persistent regurgitation, dehydration) and complications (aspiration pneumonia) require hospitalization. Eliminating predisposing factors such as hiatal hernia and management of any underlying GI or metabolic/endocrine disease that may result in vomiting or gastric hyperacidity is imperative. Treatment of esophagitis involves protecting the esophageal mucosa from further injury and reducing GER by increasing LES pressure and promoting gastric emptying with prokinetic drugs and suppressing gastric acid production.

Nursing Care

• Intravenous fluids to maintain hydration-more severe cases.
• Medications-may need to be given parenterally during hospitalization.
• Oxygen therapy-may be necessary in patients with severe aspiration pneumonia.

Diet

• Severe esophagitis-withhold food and water until regurgitation is resolved; severe cases may require gastrostomy tube feedings or rarely total parenteral nutrition.
• For patients that can be fed orally:
  • Feed small amounts in multiple feedings.
• A highly digestible-low residue diet that is moderately fat restricted and has a soft or gruel consistency is recommended; Hill's i/d, Purina EN, Iams Intestinal Plus Low-Residue, and Royal Canin Gastrointestinal Moderate Calorie are appropriate choices.

Client Education

• Discuss need to restrict food intake in patients with severe esophagitis.
• Discuss potential complications, including aspiration pneumonia, esophageal stricture, esophageal perforation, and/or esophageal motility abnormalities.

Surgical Considerations

Percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy tube placement is indicated in severe cases.

Drug(s) Of Choice

• Given parenterally (except for sucralfate) in severe cases; when administered enterally, dissolve in water and administer orally with a syringe or dropper, or by gastrostomy tube.
• Gastric acid suppressants and GI prokinetic drugs are the most established treatments for esophagitis and GER.
• Gastric acid suppression-most effective treatment for reflux esophagitis in humans.
  • H₂ receptor antagonists (H₂RAs)-famotidine 0.5–1.0 mg/kg PO, SC, IV q12h; ranitidine 2.0 mg/kg PO, SC, IV q8–12h; less effective than famotidine, may have prokinetic activity; cimetidine and nizatidine used less commonly.
• Proton pump inhibitors (PPIs) provide superior gastric acid suppression compared to H₂RAs-omeprazole 0.7–1.0 mg/kg PO q24h or 1 mg/kg PO q12h for more rapid onset of activity and greater efficacy; give 1 hour before a meal; pantoprazole 0.7–1.0 mg/kg IV q12–24h, lansoprazole and esomeprazole 1 mg/kg PO q24h have also been recommended.
• GI prokinetic agents-increase LES pressure and gastric emptying.
  • Cisapride 0.5–0.75 mg/kg PO q8h; more effective prokinetic than metoclopramide, must be obtained from a compounding pharmacy, must be administered enterally.
• Metoclopramide 0.2–1.0 mg/kg PO, SC q8h or 1.0–3.0 mg/kg/day CRI; the higher end of the dose range may be necessary depending on the response.
• Sucralfate 0.5–1 g PO q8h as a suspension or tablets mixed into a slurry with water. Sucralfate is a mucosal protectant that binds to inflamed tissue creating a protective barrier, stimulates growth factors, mucus and bicarbonate; efficacy for esophagitis has been questioned as drug activity requires an acidic environment and the esophageal environment is not expected to be acidic.
• Antibiotics-indicated with aspiration pneumonia, severe esophageal ulceration or esophageal perforation.
• Analgesics to manage esophageal pain.
  • Lidocaine solution (2.0 mg/kg PO q4–6h) for local analgesia.
• Tramadol 2–4 mg/kg PO q8–12h.

• Anti-inflammatory dosage of corticosteroids (e.g., prednisone 0.5–1 mg/kg PO per day or divided q12h) may decrease fibrosis and esophageal stricture formation in severe cases; controversial and efficacy has not been supported by the literature. Should not be given when there is evidence of aspiration pneumonia.

Contraindications

None

Precautions

None

Possible Interactions

Sucralfate may interfere with gastrointestinal absorption of other drugs and it is best to separate dosing by 2 hours from other drugs; may not be clinically important.

Alternative Drug(s)

• Fentanyl analgesic patches-may be useful in severe cases of painful esophagitis.
• Ranitidine 2.0 mg/kg PO q12h, nizatidine 2.5–5.0 mg/kg PO q24h and erythromycin 0.5–1.0 mg/kg PO, IV have GI prokinetic effects and may be alternate or additive drugs.

Patient Monitoring

• Patients with mild esophagitis do not necessarily require follow-up endoscopy; tracking of clinical signs may be sufficient.
• Consider follow-up endoscopy in patients with ulcerative esophagitis and those at risk for esophageal stricture.

Prevention/Avoidance

• Consider omeprazole 1 mg/kg PO to reduce gastric acidity 4 hours prior to anesthesia and cisapride 1 mg/kg 12–18 hours prior to anesthesia to reduce GER during anesthesia and surgery.
• Maropitant citrate has been recently shown to reduce nausea and vomiting post hydromorphone administration; may be useful to prevent vomiting and regurgitation associated with the use of anesthesia and opiod premedications.
• If gastroesophageal reflux is the cause of esophagitis, owners should avoid late-night feedings; this tends to diminish gastroesophageal sphincter pressure during sleep.
• Proper patient preanesthesia fasting decreases the risk of GER; general recommendations are 0–2 hours preanesthesia removal of water and 6–8 hour preanesthesia removal of food.
• Follow oral administration of capsules and tablets with 5–10 mL bolus of water (especially for doxycycline), a meal or give with a treat such as a Pill Pocket to hasten transit time of pills to stomach. For cats coating pills with butter or applying Nutrical to the nose to stimulate licking after administration of tablets may also be effective.

Possible Complications

• Esophageal stricture formation.
• Esophageal perforation (rare).
• Aspiration pneumonia.
• Permanent esophageal dysmotility.
• Chronic reflux esophagitis.
• Barrett's esophagus (rare complication of chronic reflux esophagitis in cats).

Expected Course and Prognosis

• Best results when patients are treated with a gastric acid suppressant (e.g., famotidine or omeprazole), a GI prokinetic (e.g., cisapride or metoclopramide), and a mucosal protectant (e.g., sucralfate).
• Mild esophagitis-generally favorable prognosis.
• Severe or ulcerative esophagitis-greater potential for complications and guarded prognosis.
• Complete recovery is possible if the disorder is recognized and treated before serious complications develop.

Zoonotic Potential

None

Pregnancy/Fertility/Breeding

H₂RAs, PPIs, and glucocorticoids should all be used with caution during pregnancy.

Synonyms

Esophageal inflammation

See Also

• Dysphagia
• Esophageal Diverticula
• Esophageal Foreign Bodies
• Esophageal Stricture
• Gastroesophageal Reflux
• Hiatal Hernia
• Megaesophagus
• Regurgitation

Abbreviations

• GER = gastroesophageal reflux
• GERD = gastroesophageal reflux disease
• GI = gastrointestinal
• H₂RA = H₂ receptor antagonist
• LES = lower esophageal sphincter
• NSAID = nonsteroidal anti-inflammatory drug
• PEG = percutaneous endoscopic gastrostomy
• PPI = proton pump inhibitor

Client Education Handout Available Online