Esophagitis and its causes: Who is “guilty” when acid is found “not guilty”?

Figure 1 Eosinophilic esophagitis. Endoscopic appearance of eosinophilic esophagitis; note the characteristic multiple rings throughout the esophagus resembling the tracheal aspect and described as “trachealization of the esophagus”. This finding is not common in the early stage of the disease, when tissue elasticity is still preserved by the inflammatory damage.

Figure 2 Esophageal Crohn’s disease. Endoscopic finding in a patient with esophageal localization of Crohn’s disease. Note the apthous erosions and the small ulceration similar to those usually present in the lower gastrointestinal tract. The localization at the middle tract of the esophagus, far from the esophago-gastric junction suggests to rule out the possibility of gastroesophageal reflux disease.

Figure 3 Drug-induced esophageal damage. Endoscopic view of a patient with a history of NSAIDS use. In this case two ulcers are visible, located in the middle third of the esophagus. Also in this case, as well as for Crohn’s disease, the proximal localization makes the possibility of gastroesophageal reflux disease unlikely.

Figure 4 Candida esophagitis. Endoscopic appearance in a patient with severe dysphagia under chronic steroid treatment for rheumatoid arthritis. Note the typical multiple yellow plaques interesting the entire tract of the esophageal wall and strictly adherent to the mucosa.

Figure 5 Diagnostic flow-chart proposed in patients with symptoms suggestive of esophagitis (heartburn, dysphagia, chest pain and others). The area above the dotted line includes all the possible manifestations of GERD that remains the most common etiology of symptoms. The less frequent causes are reported below the dotted line. All the possibilities deserve an accurate collection of clinical history to orientate the differential diagnosis. EoE: Eosinophilic esophagitis; NSAIDs: Non-steroidal anti-inflammatory drugs; IBD: Inflammatory bowel disease; GERD: Gastroesophageal reflux disease.