How is esophagitis treated?

Esophagitis—the inflammation of the esophageal mucosa—is managed based on its underlying cause, symptom severity, and presence of complications such as strictures or Barrett’s esophagus. The most common etiology is gastroesophageal reflux disease (GERD), but other causes include infectious agents (e.g., Candida, herpes simplex virus, cytomegalovirus—particularly in immunocompromised individuals), medication-induced injury (e.g., from NSAIDs, bisphosphonates, or potassium chloride), eosinophilic infiltration (eosinophilic esophagitis), or caustic ingestion.

For reflux-related esophagitis, first-line therapy involves proton pump inhibitors (PPIs) such as omeprazole, esomeprazole, or pantoprazole, typically administered at standard or high-dose regimens for 8 weeks. PPIs significantly reduce gastric acid secretion, allowing mucosal healing and symptom resolution in the majority of patients. Lifestyle modifications—including weight loss (if overweight), avoidance of late-night meals, elevation of the head of the bed, and elimination of dietary triggers (e.g., caffeine, alcohol, spicy or acidic foods, chocolate, and mint)—are essential adjuncts to pharmacologic treatment.

Infectious esophagitis requires targeted antimicrobial therapy: fluconazole for Candida; acyclovir or valacyclovir for HSV; and ganciclovir or valganciclovir for CMV—always guided by endoscopic biopsy and histopathologic confirmation. Eosinophilic esophagitis is managed with topical corticosteroids (e.g., swallowed fluticasone or budesonide slurry), dietary elimination strategies (e.g., six-food elimination diet), and, in select cases, biologics such as dupilumab. Drug-induced esophagitis mandates immediate discontinuation of the offending agent and supportive care, including PPIs and strict adherence to proper pill-taking techniques (e.g., taking medications upright with ample water).

Endoscopic evaluation is recommended for patients with alarm symptoms—including dysphagia, odynophagia, unexplained weight loss, gastrointestinal bleeding, or recurrent symptoms despite appropriate PPI therapy—to assess for complications and rule out malignancy. Long-term management may involve maintenance PPI therapy, periodic surveillance endoscopy (especially in patients with Barrett’s esophagus), and multidisciplinary input from gastroenterology, allergy/immunology, or infectious disease specialists when indicated.