Esophageal odynophagia

Specialty: Gastrointestinal.

• Retrosternal pain when swallowing
• painful substernal swallowing
• post-swallowing esophageal pain

Why it occurs

• Infectious esophagitis due to Candida albicans, Herpes Simplex Virus (HSV) or Cytomegalovirus (CMV), frequently in immunosuppressed patients
• Drug-induced esophagitis ("pill esophagitis" such as alendronate, doxycycline, nonsteroidal anti-inflammatory drugs, or potassium supplements impact the esophagus)
• Caustic esophagitis due to ingestion of strong acids or alkalis
• Severe gastroesophageal reflux disease with deep distal esophageal ulceration (the Angeles grade D)
• Diffuse esophageal spasm triggered by swallowing liquids at extreme temperatures.

Initial workup

Upper gastrointestinal endoscopy (EDA, urgent or scheduled; definitive method to evaluate the mucosa, take biopsies, mycological brushing and viral cultures) | Chest CT with oral water-soluble contrast (avoid barium if acute esophageal perforation is suspected) | Esophagogram with water-soluble contrast to assess secondary strictures or fistulas.

Standard management

• Systemic antifungals in candidal esophagitis — fluconazole 200-400 mg loading dose, followed by 100-200 mg daily orally or intravenously for 14-21 days; or caspofungin in refractory cases
• Specific antivirals — acyclovir 5 mg/kg IV every 8 hours for HSV; or ganciclovir 5 mg/kg IV every 12 hours for CMV
• Proton pump inhibitors at double doses — pantoprazole or esomeprazole 40 mg every 12 hours to suppress acidity and promote mucosal healing
• 2% viscous lidocaine orally (gargle and careful swallowing before eating for symptomatic pain relief, with caution to avoid aspiration).