Internal Medicine

P1: OXT/OZN/JDO P2: PSB

0521779407-E-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:10

554 Esophageal Infections and Inflammation

management

What to Do First:

■if candidiasis suspected, empiric treatment with fluconazole for 3

days; reserve endoscopy with biopsy for patients who do not respond

to therapy

■in cases of caustic injury, endoscopy should be performed within 24

hours to determine extent of injury and allow for psychiatric referral

if no injury is demonstrated

General Measures

■topical analgesics (2% viscous lidocaine swish and swallow 15 cc

orally q3–4h or sucralfate slurry1gorally QID) for patient discomfort

■liquid diet and consideration for parenteral or nasogastric feeding if

oral intake compromised

■identify predisposing conditions

■withdrawal of immunosuppressive medications if possible

■adequate control of concomitant gastroesophageal reflux disease, if

present; concomitant acid suppression is recommended for patients

with infectious esophagitis

specific therapy

■esophageal candidiasis

➣topical therapy for patients with normal immune system: Nys-

tatin, 500,000 units “swish and swallow” five times daily or clotri-

mazole troches, 10 mg dissolved in mouth five times daily) for

7–14 days

➣for immunocompromised hosts:

➣fluconazole 100 mg/day for 14–21 days

➣itraconazole 200 mg/day for 14–21 days

➣refractory cases: amphotericin B IV 0.3–0.5 mg/kg/day

■cytomegalovirus infection

➣in patients with HIV infection, restoration of the immune sys-

tem with highly active antiretroviral therapy (HAART) is the most

effective way of controlling CMV disease

➣ganciclovir 5 mg/kg q12h for 3–6 weeks

➣foscarnet 90 mg/kg IV q12h for 3–6 weeks

■herpes simplex esophagitis

➣in immunocompetent hosts, no treatment may be indicated, but

antiviral therapy may result in quicker symptom resolution

➣acyclovir 400–800 mg five times per day for 14–21 days or 5 mg/kg

IV q8h for 7–14 days