Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Oesophagitis including eosinophilic and infective causes
Essential points for quick revision.
2 min synopsisUK scopeSources checked 8 Sept 2026Clinical review pending
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Impaction, bleeding or deep infection
Inability to swallow saliva, haematemesis, severe chest pain, systemic illness or suspected perforation requires urgent endoscopic and surgical assessment rather than routine outpatient acid treatment.
Action: Keep nil by mouth when obstructed, protect the airway, resuscitate, obtain urgent specialist endoscopy and image possible transmural injury; remove a bolus without blind advancement.
Synopsis
Differentiate acid, eosinophilic, pill and opportunistic infectious oesophagitis using context and biopsy, treat the correct mechanism, and prevent impaction, bleeding, stricture and medication toxicity.
Reflux oesophagitis causes distal erosive injury from acid exposure; eosinophilic disease is patchy immune inflammation associated with dysphagia and food impaction.
Pill injury occurs where caustic tablets lodge, especially with little water or lying down, while Candida and viral ulceration occur mainly with impaired immunity.
Endoscopy describes distribution and obtains adequate biopsies; visual appearance cannot reliably distinguish every cause.
Key red flags
Recurrent food impaction or a narrow-calibre oesophagus suggests eosinophilic remodelling even when reflux symptoms coexist.
Odynophagia in an immunocompromised person raises Candida, HSV or CMV infection and requires organism-directed assessment.
Viral ulcer concern
Severe odynophagia with deep ulcers in transplant or advanced immune suppression needs biopsy-supported HSV or CMV treatment.
Investigation priorities
01
Upper-GI endoscopyFirst step
Define distribution, severity, obstruction and complications.
Management branches
Worked case: eosinophilic diseaseTreat inflammation and calibre, then prove response
A 28-year-old with asthma has a second meat impaction; emergency endoscopy shows rings, furrows and a fixed 12 mm narrowing.
Remove the bolus without delaying emergency care and take six biopsies from proximal and distal oesophagus at the index procedure, documenting that the patient was taking a PPI when sampled.
Histology shows a peak 48 eosinophils per 0.3 mm² and no alternative mucosal cause. Because the result is diagnostic despite PPI exposure, begin shared treatment planning rather than requiring a washout merely to reconfirm a positive result.
Key medicines
Budesonide orodispersible tabletFor adult eosinophilic oesophagitis, take one 1 mg orodispersible tablet in the morning and one in the evening for six weeks; induction may be extended to twelve weeks if response is inadequate. Take after a meal, place on the tongue and let it disintegrate, then swallow the budesonide-rich saliva gradually. Do not chew or swallow the tablet whole, and do not eat, drink or perform oral hygiene for at least thirty minutes afterward.Specialist initiation is required. The product should not be used in hepatic impairment and is not recommended in severe renal impairment. Avoid potent CYP3A4 inhibitors such as ketoconazole or ritonavir unless a specialist judges the combination necessary and can monitor increased systemic exposure. Check oral or oesophageal candidiasis and cumulative systemic corticosteroid effects, including adrenal suppression; maintenance and withdrawal decisions require specialist review.
Fluconazole for oesophageal candidiasisFor adult oesophageal candidiasis, give fluconazole 400 mg orally or intravenously on day 1, then 200 mg once daily for 14–30 days. After the loading dose, use 50% of the maintenance dose when creatinine clearance is 50 mL/min or less in a patient not receiving dialysis. For the cited 2 mg/mL intravenous formulation, infuse at no more than 10 mL/min and account for its sodium and fluid load; change to oral treatment when swallowing and absorption permit.Review interacting medicines, pregnancy, liver tests, renal function and QT risk; correct hypokalaemia, hypomagnesaemia and hypocalcaemia before treatment. The infusion contains 0.15 mmol sodium per mL. Lack of improvement should prompt culture or biopsy and assessment for resistant Candida or viral ulceration rather than automatic dose escalation.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 8 Sept 2026; clinical approval remains outstanding.