Distal Esophagitis: Symptoms, Causes, Treatment & Prevention

Distal esophagitis is inflammation of the lower esophageal mucosa, most commonly due to gastroesophageal reflux disease (GERD). It affects up to 10–20% of adults in Western countries.

Symptoms

• Heartburn (pyrosis) – retrosternal burning, postprandial, worse supine.
• Regurgitation – effortless return of gastric contents.
• Dysphagia – solids > liquids; may indicate stricture.
• Odynophagia – painful swallowing (suggests erosive esophagitis).
• Atypical: Chronic cough, hoarseness, asthma exacerbation, dental erosion, globus.
• Chest pain – mimics cardiac; requires exclusion.

Etiology (Multifactorial)

• GERD: Transient LES relaxations, hypotensive LES, hiatal hernia, delayed gastric emptying.
• Hiatal hernia: Disrupts LES barrier, acid pocket formation.
• Infections: Candida (immunocompromised), HSV, CMV, H. pylori (controversial role).
• Medications (pill esophagitis): Bisphosphonates, NSAIDs, doxycycline, potassium chloride, iron – taken with insufficient water / supine.
• Chemo/radiation: Direct mucosal toxicity.
• Eosinophilic esophagitis (EoE): Allergic/immune-mediated; dysphagia, rings, strictures.
• Lifestyle: Smoking, alcohol, obesity, large late meals, caffeine, chocolate, mint, fatty foods.

Diagnosis

• EGD (esophagogastroduodenoscopy) with biopsy: Gold standard. LA classification (Grades A–D). Rules out Barrett's, EoE, malignancy.
• Esophageal pH/impedance: Correlate symptoms with reflux events (acid/non-acid).
• Manometry: If surgical intervention considered.

Treatment – Stepwise

1. Lifestyle modification (first-line):
   • Head of bed elevation 6–8" (blocks, not pillows).
   • Weight loss if BMI >25.
   • Avoid triggers (individualized), late meals (<3 hrs before bed), tobacco, alcohol.
   • Small, frequent meals.
2. Pharmacotherapy:
   • PPI (omeprazole 20–40 mg daily 30 min before breakfast) – 8 wk trial; maintenance if recurrent.
   • H2RA (famotidine) – nocturnal breakthrough, step-down.
   • Antacids / alginate (Gaviscon) – on-demand.
   • Sucralfate – mucosal coating (limited evidence).
3. Endoscopic therapy: Dilation for peptic stricture; ablation (RFA) for Barrett's dysplasia.
4. Surgery (refractory): Laparoscopic Nissen fundoplication; LINX device; TIF (transoral incisionless fundoplication).

Prevention = Long-Term Management

Sustained lifestyle adherence + lowest effective PPI dose + surveillance endoscopy if Barrett's (every 3–5 yrs non-dysplastic).

Persistent symptoms despite PPI BID warrant referral for functional testing and EoE exclusion.