Sandbox esophagitis medical therapy

# Overview
Treatment of esophagitis should be directed against the specific etiology.

# Medical Therapy
Treatment depends on the specific cause. Reflux disease may require medications to reduce acid. Infections will require antibiotics.
- Medications that block acid production, like heartburn drugs.
- Antibiotics, antifungals, or antivirals to treat an infection.
- Pain medications that can be gargled or swallowed.
- Corticosteroid medication to reduce inflammation.
- Intravenous (by vein) nutrition to allow the esophagus to heal and to reduce the likelihood of malnourishment or dehydration.
- Endoscopy to remove any lodged pill fragments.
- Surgery to remove the damaged part of the esophagus.
While being treated for esophagitis, there are certain steps you can take to help limit discomfort.
- Avoid spicy foods such as those with pepper, chili powder, curry, and nutmeg.
- Avoid hard foods such as nuts, crackers, and raw vegetables.
- Avoid acidic foods and beverages such as tomatoes, oranges, grapefruits and their juices. Instead, try imitation fruit drinks with vitamin C.
- Add more soft foods such as applesauce, cooked cereals, mashed potatoes, custards, puddings, and high protein shakes to your diet.
- Take small bites and chew food thoroughly.
- If swallowing becomes increasingly difficult, try tilting your head upward so the food flows to the back of the throat before swallowing.
- Drink liquids through a straw to make swallowing easier.
- Avoid alcohol and tobacco.

# Esophagitis of Infectious Etiology
The following pathogens have been reported in the infectious esophagus:
- Fungal: Candida albicans, Candida glabrata, Histoplasma capsulatum, Saccharomyces cerevisiae, Cryptococcus neoformans
- Viral: Cytomegalovirus, herpes simplex virus, human immunodeficiency virus, Epstein-Barr virus, varicella-zoster virus, human papillomavirus
- Bacterial: Mycobacterium avium-intracellulare, Mycobacterium tuberculosis, Actinomyces
- Protozoal: Cryptosporidium, Pneumocystis jirovecii, Leishmania

## Antimicrobial Regimen  Pathogen-Based Therapy
The selection of pharmacologic agent should be directed against the specific causative pathogen.

### Candida
- Preferred regimen
Fluconazole 100200 mg/day PO/IV for 14-21 days AND
Maintenance therapy with fluconazole 100200 mg/day PO in AIDS patients
- Fluconazole 100200 mg/day PO/IV for 14-21 days AND
- Maintenance therapy with fluconazole 100200 mg/day PO in AIDS patients
- Alternative regimen
Itraconazole suspension 100200 mg PO bid OR Voriconazole 200 mg PO bid OR Amphotericin B 0.30.7 mg/kg/day IV for 7 days OR Caspofungin 50 mg/day IV following a 70 mg loading dose OR Micafungin 150 mg/day IV OR Anidulafungin 50 mg/day IV following a 100 mg loading dose
- Itraconazole suspension 100200 mg PO bid OR Voriconazole 200 mg PO bid OR Amphotericin B 0.30.7 mg/kg/day IV for 7 days OR Caspofungin 50 mg/day IV following a 70 mg loading dose OR Micafungin 150 mg/day IV OR Anidulafungin 50 mg/day IV following a 100 mg loading dose

### Herpes simplex virus
- Preferred regimen
Acyclovir 5 mg/kg IV q8h for 714 days OR Acyclovir 400 mg 5 times daily PO for 1421 days OR Valacyclovir 1 g PO tid for 1421 days  maintenance therapy
- Acyclovir 5 mg/kg IV q8h for 714 days OR Acyclovir 400 mg 5 times daily PO for 1421 days OR Valacyclovir 1 g PO tid for 1421 days  maintenance therapy
- Alternative regimen
Famciclovir 500 mg bid PO for 1421 days OR Foscarnet 90 mg/kg q12h IV for 714 days
- Famciclovir 500 mg bid PO for 1421 days OR Foscarnet 90 mg/kg q12h IV for 714 days

### Cytomegalovirus
- Preferred regimen
Ganciclovir 5 mg/kg IV q12h for 1421 days AND
Maintenance therapy with Ganciclovir 5 mg/kg/day IV or 6 mg/kg/day IV 5 days per week in AIDS patients
- Ganciclovir 5 mg/kg IV q12h for 1421 days AND
- Maintenance therapy with Ganciclovir 5 mg/kg/day IV or 6 mg/kg/day IV 5 days per week in AIDS patients
- Alternative regimen
Foscarnet 90 mg/kg IV q12h for 1421 days, then Foscarnet 90120 mg/kg/day IV for maintenance in AIDS patients OR Valganciclovir 900 mg PO bid, then 900 mg PO qd for maintenance in AIDS patients
- Foscarnet 90 mg/kg IV q12h for 1421 days, then Foscarnet 90120 mg/kg/day IV for maintenance in AIDS patients OR Valganciclovir 900 mg PO bid, then 900 mg PO qd for maintenance in AIDS patients

### Aphthous ulceration in immunocompromised hosts
- Preferred regimen
Prednisone 40 mg/day PO for 14 days, tapered over 48 weeks
- Prednisone 40 mg/day PO for 14 days, tapered over 48 weeks
- Alternative regimen
Thalidomide 200 mg/day PO
- Thalidomide 200 mg/day PO

# Eosinophilic Esophagitis
The optimal treatment of eosinophilic esophagitis remains uncertain.  The endpoints of therapy of eosinophilic esophagitis include improvements in clinical symptoms and esophageal eosinophilic inflammation.  An eight-week course of therapy with topical corticosteroids (fluticasone 88440 mcg/day for children or 8801760 mcg/day for adults or budesonide 1 mg/day for children or 2 mg/day for adults) may be used as the first-line pharmacologic therapy.  Patients without symptomatic and histologic improvement after topical steroids may benefit from a longer course or higher doses of topical steroids, systemic steroids with prednisone, dietary elimination, or endoscopic dilation.  Evaluation by an allergist for coexisting atopic disorders and food and environmental allergens is advisable.  Allergen elimination usually leads to improvement in dysphagia and reduction of eosinophil infiltration.  Graduated dilation of esophageal stricture should be performed with caution to minimize the risk of iatrogenic perforation.

# Contraindicated Medications
Reflux esophagitis is considered an absolute contraindication to the use of the following medications:
- Dicyclomine