Esophagitis and Gastroduodenal Disorders: Symptoms and treatment

The esophagus, stomach and part of duodenum form the foregut structures. Esophagitis is the inflammation of the mucosa of the esophagus. Gastroduodenal disorders include many commonly encountered disorders like dyspepsia and peptic ulcers. How would you know you had such a disorder, and what is the treatment?

Disorders of the esophagus

The esophagus or the "food pipe" is a hollow organ which propels food to the stomach. It is about 25 cm in length. It starts at about 15 cm from the lower incisor teeth and ends at the gastroesophageal junction, which is about 40 cm from the lower incisor teeth. The following are some of the most common esophageal disorders.
 

Gastroesophageal reflux disease

Gastroesophageal reflux disease is the most common condition affecting the esophagus. Gastroesophageal reflux occurs physiologically in all persons, when contents of stomach reflux (return, are brough back up) into the esophagus. It is called gastroesophageal reflux disease when the reflux produces esophageal and/or extraesophageal symptoms or causes damage to the esophagus or other nearby organs.

The most common symptoms of gastroesophageal disease include heartburn, regurgitation, difficulty in swallowing, nausea and belching. Other less common symptoms of this disorder include chest pain, cough, hoarseness of voice, feeling of lump in the throat, dental erosion and sore throat.

The treatment of gastroesophageal reflux disease includes:

• Lifestyle modifications like:

1. Weight reduction
2. Avoiding bedtime snacks
3. Going to bed 2+ hours after eating food
4. Head elevation while sleeping, by using pillows to prop the upper body up
5. Avoiding alcohol, smoking, spicy food, coffee, citrus, cola

The other approaches to managing GERD are more invasive:

• Medications like proton pump inhibitors ( eg.omeprazole)
• Surgery ( fundoplication)
• Endoscopic therapy like sewing, injection and radioablation of the lower esophageal sphincter

Esophagitis - inflammation of mucosa of the esophagus

Esophagitis is a condition characterized by an inflammation of the mucosa (inner lining) of the esophagus. The symptoms of esophagitis include chest pain and pain while swallowing. The treatment for esophagitis depends on the underlying cause. Some of the causes of esophagitis are:

Gastroesophageal reflux disease

Recurrent reflux of acid contents from the stomach causes inflammation of the mucosa of esophagus resulting in esophagitis. The acid reflux related esophagitis symptoms include heartburn, regurgitation, difficulty and pain during swallowing. The acid reflux induced esophagitis treatment includes medications like proton pump inhibitors and lifestyle modifications as mentioned above.

Infection

Esophageal infection resulting in esophagitis commonly occurs in those people with a suppressed immune system. The most common infections that cause esophagitis are Candida, herpes simplex and mycobacterium tuberculosis. Treatment depends on the cause. Candida infection is treated with antifungal medications like fluconazole. Herpes is treated with acyclovir. Tuberculosis is treated with anti-tuberculous medications.

Medication induced

Medication induced esophagitis or the pill esophagitis can occur at any age. Some of the medications that are commonly associated with esophagitis are tetracycline, nonsteroidal anti-inflammatory drugs, ferrous sulphate and medications used in the treatment of cancer. Oral esophagitis treatment, in pill form, consists of proper administration of medication helps to prevent pill esophagitis. Medications should be swallowed with at least 8 ounces of clear liquid. Patients should remain upright for at least 30 minutes following the ingestion of their medication.

Radiation induced

Esophagitis can occur in the second or third week of standard thoracic radiotherapy.  The affected patients develop esophagitis symptoms like difficulty and pain during swallowing. Symptoms may persist for many weeks after completion of high dose radiotherapy.  The late complication includes narrowing of the esophagus.

Gastroduodenal disorders

The stomach is a “J” shaped canal which is continuous with the esophagus above and duodenum below.  Its function includes storing large quantities of recently ingested food, initiating the digestive process and releasing its contents in a controlled fashion in to the duodenum, which has a smaller capacity.

The duodenum is the first part of small intestine.  It is an extension of the stomach above and the jejunum below. The liver and the pancreas are connected to duodenum through the bile duct and the pancreatic duct respectively which open in to a common channel to enter the duodenum. Most of the digestion of food takes place in the duodenum.

The gastroduodenal disorders can be organic or functional. The gastroduodenal disorder symptoms are mostly nonspecific. The gastroduodenal disorder symptoms include upper abdominal pain or discomfort, nausea, vomiting and abdominal bloating. The gastroduodenal disorder treatment depends on whether it is functional or organic. The most common gastroduodenal disorders include the following.
 

Functional dyspepsia

Functional dyspepsia refers to persistent or recurrent dyspepsia (an upset stomach) in patients who have undergone tests including endoscopy and have not been found to have an obvious specific cause of their symptoms. Dyspepsia is defined as pain or discomfort centered in the upper abdomen. The symptoms of this gastroduodenal disorder include:

• Pain in the upper abdomen
• Discomfort in the upper abdomen
• A feeling of fullness of the stomach
• Feeling full after a small quantity of food

The treatment of functional dyspepsia includes:

• Reassurance
• Lifestyle modification

1. Stopping smoking
2. Weight reduction
3. Avoiding coffee, chocolates and excessive alcohol
4. Avoiding medication associated with dyspepsia if possible (e.g. theophylline, NSAIDs. etc)
5. Eating regular meals

• Medications

1. Antacids
2. H2 receptor antagonists like ranitidine
3. Proton pump inhibitors like Omeprazole
4. Prokinetics like metaclopramide

Belching disorder

During eating and drinking some amount of air is swallowed which is belched out and this is considered a normal phenomenon. Belching is considered a disorder only when it is troublesome. Belching may accompany gastroesophageal reflux disease and dyspepsia. The treatment of belching disorder includes-

• Reassurance
• Dietary modifications

1. Avoiding sucking candies or chewing gums
2. Eating slowly
3. Avoiding carbonated drinks

• Behavioral therapy

Nausea and vomiting disorders

Nausea is the unpleasant sensation of impending vomiting felt in the upper abdomen or throat. Vomiting is forceful expulsion of stomach or intestinal contents through the mouth associated with contraction of abdominal and chest muscles. This group includes chronic idiopathic nausea, functional vomiting and cyclic vomiting syndrome.

A person is said to be suffering from chronic idiopathic nausea if he has bothersome nausea occurring several times a week in the last three months and the tests done for metabolic diseases and endoscopy does not reveal anything.

Functional vomiting is diagnosed:

• If the person on an average has at least one episode of vomiting per week
• If the person does not suffer from eating disorder or any major psychiatric illness
• If the vomiting is not self induced  
• If there is no chronic cannabinoid use
• If there is no abnormalities in the central nervous system
• If the tests for metabolic diseases does not reveal anything

Cyclic vomiting syndrome is diagnosed with the following criteria

• Stereotypical episodes of vomiting with acute onset
• Vomiting episodes last for less than one week
• No nausea and vomiting between episodes

The treatment includes:

• Medications to control vomiting like ondansetron and alosetron
• Low dose antidepressants
• Adequate nutrition
• Anti-migraine medication if there is family history of migraine

Rumination syndrome

Rumination syndrome is a disorder characterized by repeated regurgitation of recently ingested food which is followed chewing and swallowing of the food again. It can occur in both males and females of all ages. Rumination starts within minutes of starting a meal. There will no nausea or retching. Each episode lasts for 1-2 hours. The food that is regurgitated is partially digested.
Treatment of rumination syndrome includes:

• Reassurance
• Behavioral therapy that includes diaphragmatic breathing techniques
• Proton pump inhibitors if there are associated symptoms of acid reflux like heartburn

Gastritis and gastropathies

Gastritis is a condition characterized by inflammation of the inner lining of the stomach. The various symptoms of this gastroduodenal disorder are pain in the upper abdomen, nausea, vomiting and bleeding. Gastropathies are disorders characterized by erosions and other defects of the inner lining of the stomach without features of inflammation and cause symptoms like upper abdominal pain, nausea and vomiting. The various causes of gastritis and gastropathies are:

• Infections
• Granulomatous diseases like Crohn’s disease
• Distinctive forms like eosinophilic gastritis
• Nonsteroidal anti-inflammatory disease
• Alcohol intake
• Cocaine
• Stress
• Bile reflux
• Zollinger Ellison Syndrome

The treatment of gastritis and gastropathies depends on the underlying condition. Ingestion of green tea is also found to reduce the risk of gastritis.
 

Read More: Esophagogastroduodenoscopy: What to Expect with EGD

Peptic ulcer

Peptic ulcer is a common gastroduodenal disorder that affects individuals all around the world. An ulcer is a defect in the inner lining of the gastrointestinal tract. It could be either a gastric ulcer or a duodenal ulcer. The two most common causes of peptic ulcer are Helicobacter pylori infection and intake of non-steroidal anti-inflammatory drugs which are used as pain killers. The other causes of peptic ulcer includes medications used for chemotherapy, medications used for osteoporosis like Alendronate, conditions like Zollinger Ellison Syndrome which is characterized by increased secretion of acid in the stomach.

Peptic ulcer can be confirmed with upper gastrointestinal endoscopy. Treatment of peptic ulcer includes the following –

• Medications like proton pump inhibitors ( eg.omeprazole), H2 receptor antagonist ( eg.ranitidine)
• Eradication of H.pylori infection with antibiotics
• Avoiding non-steroidal anti-inflammatory drugs
• Endoscopic therapy which includes injection methods, thermal methods and mechanical methods
• Surgery is indicated when there is profuse bleeding and all the other measures fail to control bleeding.