Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 5: Complaint-Specific Workups

Esophageal Problems

Background

Esophageal problems in HIV-infected patients include difficulty swallowing (dysphagia) or midline retrosternal pain when swallowing (odynophagia). Pain may be diffuse throughout the esophagus or localized in specific areas.

Several conditions may cause esophageal problems. Of the infectious causes of dysphagia in HIV-infected patients, Candida is the most common (50-70%). Drug-induced dysphagia, gastroesophageal reflux disease (GERD), vomiting, and hiatal hernia can also cause esophagitis. Less commonly, neoplasm or another cause of stricture may produce symptoms. Neuromuscular or neurological causes may be seen in patients with advanced AIDS.

If untreated, esophageal problems may result in esophageal ulcers, scarring of the esophagus, dehydration, and weight loss.

S: Subjective

The patient may complain of difficulty swallowing, a feeling of something being "stuck in the throat," retrosternal pain when eating, "hiccups," indigestion ("heartburn"), acid reflux, nausea, vomiting, or abdominal pain.

The history should include the following:

• Medications (prescription and over-the-counter) and herbal supplements, current and past
• Concurrent gastrointestinal (GI) symptoms, such as abdominal pain or diarrhea
• Recent dietary history
• Location and characteristics of pain (diffuse or focal)
• Oral thrush
• Aphthous ulcers
• Cytomegalovirus (CMV)
• Candida esophagitis
• GERD
• Hiatal hernia

O: Objective

Include the following in the physical examination:

• Measure vital signs (temperature may be elevated with certain infections, such as CMV, but not with herpes simplex virus [HSV], candidiasis, or idiopathic ulcers).
• Record weight (and compare with previous weights).
• Assess for oral candidiasis, lesions, and masses.
• Examine optic fundi to evaluate for CMV retinitis (in patients with CD4 counts of <50-100 cells/µL).
• Palpate for thyroid enlargement.
• Palpate the neck for lymphadenopathy.
• Assess the abdomen for masses, tenderness, and organomegaly.
• Perform a rectal examination to obtain stool for occult blood.
• Perform a neurologic examination.
• Check the CD4 count and HIV viral load to determine the level of immunosuppression and assess the risk of opportunistic infections as causes of esophageal complaints.

A: Assessment

Common causes of esophageal problems are as follows:

• Candidiasis (common with a CD4 count of <250 cells/µL or recent exposure to steroids or antibiotics)
• Most medications, including antiretroviral agents, can cause nausea and GI-related symptoms. The following medications are commonly associated with difficulty swallowing or heartburn: aspirin, nonsteroidal antiinflammatory drugs, potassium chloride, iron, tetracycline, theophylline, anticholinergic agents, calcium channel blockers, meperidine, and progesterone tablets.
• Foods can irritate the esophagus, including citrus fruits, mints, coffee, chocolate, and spicy foods.
• GERD

Less common causes of esophageal problems include:

• CMV; HSV; idiopathic or aphthous ulcers
• Kaposi sarcoma, lymphoma, tuberculosis, Mycobacterium avium complex (MAC), histoplasmosis
• Cardiac chest pain

P: Plan

Diagnostic Evaluation

Diagnosis often can be made on clinical grounds; in this case, empiric treatment may be initiated (see below). If the diagnosis is unclear, consider endoscopy or radiographic imaging (eg, CT or barium swallow).

Treatment

Determine whether the patient is able to swallow pills before giving oral medications. If pills are not tolerated, the patient may need liquids or troches.

For patients with severe oral or esophageal pain, viscous lidocaine 1% 5-10 mL 2-4 times daily (with swallowing precautions) or Magic Mouthwash (viscous lidocaine 1%, tetracycline, Benadryl, and nystatin compounded 1:1:1:1) may be tried.

Other treatments may depend on the underlying cause:

• Esophageal candidiasis: Fluconazole (Diflucan) is the drug of choice. If symptoms resolve within 7-10 days, no further testing is required. See chapter Candidiasis, Oral and Esophageal for more options and for dosing.
• Medication-related: Remove the offending drug(s), and institute a trial of H2 blockers or proton pump inhibitors (PPIs) as appropriate.*
• Food-related: Modify the diet and institute a trial of H2 blockers or PPIs as appropriate.*
• GERD: For nonpharmacologic treatment, in cases of obesity, counsel patients to lose weight, stop smoking, elevate the head of the bed, eat smaller meals, avoid eating food 2-3 hours before bedtime, and reduce fat in the diet to ≤30% of calorie consumption.
• "Heartburn" or reflux: Patients whose primary symptoms are more typical of "heartburn" or reflux, especially those with a history of GERD, should receive a trial of H2 blockers or PPIs as appropriate.* Some patients will require both an H2 blocker and a PPI to control symptoms. Reevaluate after 1-2 weeks; if symptoms are controlled, treat for 8 weeks, then reduce the dosage to the lowest effective amount. Patients may require maintenance therapy for an indefinite period because of the high likelihood of recurrence.
• CMV: Treat with anti-CMV medications (eg, oral valganciclovir). See chapter Cytomegalovirus Disease for details.
• HSV: Treat with antiviral medications including acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex). See chapter Herpes Simplex, Mucocutaneous.
• Aphthous ulcers: These may respond to oral corticosteroids (prednisone 40 mg/d for 7-14 days, tapered to 10 mg per week for 4 weeks; a shorter course may be effective for small ulcers). Alternatively, a combination of H2 blockers* and sucralfate (Carafate) may be effective. In some circumstances, thalidomide 200 mg every 24 hours may be used. (Note: Thalidomide is teratogenic, and women of childbearing potential are not candidates for this therapy unless the benefits clearly outweigh the risks and appropriate prevention of pregnancy is undertaken.) Up to 40-50% of patients with aphthous ulcers experience relapse and require repeat treatment.
• Neoplastic disease requires referral to an oncologist.

* Caution: PPIs and H2 blockers interfere with the absorption of atazanavir. PPIs are contraindicated in patients taking atazanavir (Reyataz). H2 blockers may be used cautiously in patients on ritonavir-boosted atazanavir, if they are separated from the atazanavir doses by 12 hours.

Esophageal conditions that do not resolve with treatment require referral to a GI specialist for diagnostic endoscopy, with biopsy and brushing for histopathology and cultures as appropriate.

Diet

It is important that patients maintain adequate caloric intake, preferably with foods and liquids that can be swallowed easily. Nutritional supplements along with soft, bland, high-protein foods are recommended. Refer to nutritionist as needed.

References

• Dieterich DT, Poles MA, Cappell MS, et al. Gastrointestinial Manifestations of HIV Disease, Including the Peritoneum and Mesentery. In: Merigan TC, Bartlett JG, Bolognesi D, eds. Textbook of AIDS Medicine, 2nd ed. Baltimore: Williams & Wilkins; 1999:542-6.
• Sande MA, Eliopoulos GM, Moellering RC, et al. The Sanford Guide to HIV/AIDS Therapy, 14th ed. Hyde Park, VT: Antimicrobial Therapy, Inc.; 2005.
• Uphold CR, Graham MV. Clinical Guidelines in Adult Health, 2nd ed. Gainesville, FL: Barmarrae Books; 1999.
• Wilcox CM, Monkemuller KE. Gastrointestinal Disease. In: Dolin R, Masur H, Saag MS, eds. AIDS Therapy. New York: Churchill Livingstone;1999:752-56.