Candidiasis of the esophagus

Candidiasis is an infectious disease caused by yeast-like fungi of the genus Candida that affect the mucous tissue, skin and internal organs. In total, there are over 80 species of representatives of the genus Candida. Medical statistics say that esophageal candidiasis is affected by about 0.7-1.5% of all patients with gastroenterological disorders.

The increase in morbidity is due to the increase in people suffering from immunodeficiency, the success in transplanting donor organs and immunosuppressive therapy, as well as the prolonged intake of antibacterial drugs. Generalized fungal infections are not easily amenable to therapy and can lead to death of the patient( for invasive candidiasis, mortality is approximately 34%), so timely diagnosis and adequate treatment of esophageal candidiasis is important.

Reasons for

Representatives of the genus Candida are present in the oral cavity and in a healthy person, but their growth is inhibited by bacteria by commensals. Infection with fungi is possible endogenously and exogenously. In the first variant, infection occurs due to activation of saprophyte fungi( as a concomitant disease), and when exogenous spores penetrate from the outside or directly interact with the carrier of infection.

With good immunity, fungi do not show pathogenic properties, and when immunodeficiency can develop systemic candidiasis, in which the infection affects the oral cavity, esophagus, genitals. Whether systemic candidiasis will show depends on the amount of microorganism that has penetrated, its infectiousness, its genetic and species affiliation. Candidiasis of the esophagus often develops as a result of penetration of the fungus from the mucous cavity of the mouth and throat. An infection develops if a person has various pathologies of physiological, anatomical and protective mechanisms.

According to doctors, the cause of esophagial candidiasis can be:

• use of antibacterial drugs;
• application of injections of corticosteroids;
• decreased gastric acidity( or antacids);
• alcoholism;
• diabetes;
• poor nutrition;
• old age;
• worsening of esophageal contractility;
• the effects of poisoning;
• organ transplant;
• is enteral( probe) and parenteral( intravascular) nutrition.

Thus, in diabetes mellitus, the concentration of glucose in the blood increases, which increases the colony of fungi, as the function of granulocytes is weakened. When the parathyroid gland and adrenal gland deteriorate, the calcium-phosphorus metabolism is disrupted, and this reduces the local immunity of the esophagus.

Because of the small amount in the diet of protein and the use of low-calorie food, the function of the immune system worsens. With a decrease in the synthesis of hydrochloric acid, the microorganism begins to multiply intensively in the stomach, optimal for it is the medium with a pH of 7.4, and at pH 4.5 the growth of fungi is impossible.

The formation of ulcers occurs infrequently( noted, as a rule, in patients with granulocytopenia)

Mechanism of development of the disease

The clinic of esophageal candidiasis is different. First, isolated white or yellow small foci appear on the affected areas of the esophageal tube, which somewhat rise above the mucous membrane. Then these foci can merge and form a dense plaque, and the microorganism itself is introduced into submucosal and muscle tissue, vessels.

Education consists of dead cells of the mucosa, fungi, bacteria and exudate. On the mucosa of the esophagus, films are formed which, in a severe case, can completely cover the lumen of the tube. At a microscopic examination, cells and threads of the mycelium are identified. In rare cases, the cells of the esophagus wall die, necrotic areas are formed, which leads to a phlegmous inflammation of the organ and mediastinum, and this can lead to death.

Depending on the severity of the course of the disease and the depth of lesion of the esophagus tissues, three stages of the disease are distinguished. In the first stage of the disease, separate foci with a white coating are visible on the mucosa, and the mycelium of the fungus is introduced between the cells. In the second stage, the foci merge with the plaque, and the filaments of the mycelium germinate into the submucosal layer of the esophagus. In the third stage, the threads of the fungus damage the muscle tissue.

Symptoms of

The signs of esophageal candidiasis include:

• dysphagia( difficulty swallowing);
• single-phonation( pain behind the breastbone when swallowing);
• retrosternal pain;
• heartburn;
• nausea, sometimes vomiting, in which it is possible to see films( pseudomembranes);
• anorexia;
• diarrhea( mucus is present in the feces).

The degree of manifestation of dysphagia ranges from a slight difficulty swallowing to the presence of severe pain, resulting in the patient is unable to take food and water, which can lead to secondary dehydration. Digestion can be disturbed as a result of damage to the fungus of the stomach and intestines.

Symptoms of the disease do not appear in 25-30% of people suffering from esophageal candidiasis

Complications of esophageal candidomas develop rarely. But the disease can lead to bleeding from the esophagus or its perforation, to tissue necrosis and the development of the inflammatory process in the mediastinum, to the formation of candidal sepsis, and secondary occlusion of the lumen by the mycetoma has also been described.

Diagnosis of

Suspected candidiasis develops if the patient has a history of factors that can lead to the formation of an esophageal infection, and if there are difficulties or pain when passing a food lump through the esophagus. Sometimes to make a diagnosis it is enough to conduct a physical examination of the patient, since most patients suffer from candidal stomatitis or chronic mucocutaneous cutaneous candidiasis.

For initial testing of the esophagus condition, radiography with a contrast agent is usually prescribed. In the early stages of the disease, this study has no significant diagnostic value, since it allows us to detect only nonspecific changes that occur with any kind of esophagitis.

Signs of acute inflammation of the esophagus caused by Candida are pathologies of the mucosa with distinct edges( they can be linear or of various irregular shapes).With the defeat of large areas of defects merge, because of what they look on the picture as a bunch of grapes, and the body walls become "fleecy."The presence of large ulcers with even edges does not confirm candidal esophagitis.

The study also helps to detect a breach of the esophageal contractility and its narrowing due to the presence of pseudomembranes. For more information, as a rule, the patient is assigned x-rays with double contrast. The effectiveness of the method reaches 70%.To detect esophageal infections, a cytological brush or balloon catheter can be used.

A medical instrument is inserted through the mouth or nasal passages, and a probe is used to prevent contamination( cross contamination).Taken from the mucosa of the esophagus, the sample is evaluated in a laboratory where the presence of expanding yeast cells, mycelium and pseudomycelia is checked under a microscope. The technique is sensitive to 88% and is specific to almost 100%.

Even a normal X-ray picture of the esophagus does not exclude the presence of Candidiasis

The most effective diagnostic method is the endoscopic examination of the esophagus. With fungal infection on the esophagus, easily detached loose fibrous films are found, under which inflamed and edematous mucosa. During endoscopy, material for cytological and histological examination is taken. With the appearance of ulcers on the mucosa, multiple tissue biopsy allows the exclusion of additional traumatizing mucous processes.

Treatment of

Pharmacology in its arsenal has many tools that can destroy the fungi of the genus Candida. However, treatment of esophageal candidiasis remains a problem, because some medicines are not effective enough, others have many side effects, in addition to antimycotic drugs, the microorganism develops resistance rather quickly.

In the treatment of fungal infection of the esophagus, oral therapy is recommended first, and intravenous medications are only used if there are contraindications to oral administration of the medication. In therapy, antifungal agents are used in one of three groups. The most effective are azoles. These can be nonabsorbable azoles( miconazole, clotrimazole) or having a systemic effect( ketoconazole, Itraconazole, Fluconazole).

Like all azoles, the components affect the permeability of the cell membrane of the pathogen, as a result of which the biosynthesis of ergosterol is disrupted, which leads to cell death.

Clotrimazole and miconazole are not absorbed in the gastrointestinal tract( GI tract).They are prescribed to patients with mild degree of esophageal injury not suffering from immunodeficiency. Ketoconazole( Oronazol, Nizoral) is effective enough and can be prescribed to patients with AIDS.It quickly penetrates into the organs and tissues, but it does not overcome the blood-brain barrier.

To absorb the drug in the stomach should be an acidic medium, if hydrochloric acid is not enough, then the bioavailability of the agent is reduced. Also, Catoconazole can adversely affect the synthesis of testosterone and cortisol. Intraconazole( Sporanox) is prescribed at 200 ml per day, a gradual increase in dose leads to an increase in the half-life of the drug, which increases its effectiveness.

Absorption of the active substance decreases with increasing acidity of the gastric juice. The agent can be prescribed even to patients with renal insufficiency. Fluconazole( Diflazone, Forkan, Diflucan, Flukostat) is equally absorbed and with increased and with reduced acidity of gastric juice. It is almost not metabolized, which means it is excreted unchanged in urine.

The drug does not affect the production of androgens, passes through the blood-brain barrier( in brain tissue), minimally binds to proteins. The half-life of the drug is about 30 hours, therefore, the frequency of administration is much less than other antimycotic agents. In addition, Fluconazole improves immunity.

Adverse effects in ketoconazole, fluconazole and Itraconazole appear with an increase in the daily dosage of the drug and are manifested in nausea, a violation of the synthesis of steroids, a change in the metabolism of cyclosporine, a worsening of the liver cells.

In addition to etiotropic treatment of candidiasis, supportive therapy may be needed, which may even be lifelong.

The next group of drugs used to fight the fungus is polyene antibiotics( Amphotericin, Nystatin).The active substance is combined with the sterols of the cell membranes of the infectious agent, which leads to a change in its permeability and a violation of the barrier function. Medicines based on nystatin( Antikandin, Mikostatin, Fungicidin) are more often used for the therapy of candidal stomatitis. Amphotericin( Fungizol, Amphostat) is administered intravenously by drop or by oral route.

The period of its half-life is 1-2 days, but since it accumulates in the tissues, then with prolonged use the time can increase up to 15 days. The medication has a number of side effects, which although reversible, but still restrict its use( it affects the work of neurons, hepatocytes, kidneys, causes local irritation and allergic reactions, dyspeptic syndrome, fever).Amphotericin is prescribed, if treated with azoles it makes no sense because of ineffectiveness.

The newest group of antimicrobials are the candida( Kapsofungin).They are able to destroy most of the fungi of the genus Candida, because they interfere with the formation of the wall of the fungal cell. In the treatment of fungal infection of the esophagus, first drugs are given from the group of azoles, and if resistance is developed to them, the dose of the drug is increased.

If therapy still does not give the desired result, then switch to another remedy from the same group or prescribe a solution of Itraconazole in a large dose. In the absence of a therapeutic effect of taking 400 mg of azole per day, the reception of Amphotericin is indicated. The duration of the drug course antimycotic drugs depends on the degree of defeat of the esophagus and the stage of the disease.

In addition to specific therapy, the patient is recommended:

• reception of funds that normalize the intestinal microflora;
• use of medicines that increase immunity;
• special diet;
• folk remedies.

Dietary nutrition helps to protect the esophagus from mechanical, chemical and thermal effects of food, which means it will be faster to restore the mucosa. It is necessary to exclude carbohydrates from the diet, since sugar is a nutrient medium for yeast-like fungi. Also from the menu you need to remove whole milk. If there are difficulties with swallowing food, then all products and dishes that cause increased secretion of gastric juice and contain coarse fiber fall under the ban.

To remove the severity of the inflammatory process, infusions and decoctions of herbs with anti-inflammatory action( chamomile, yarrow, calendula, sage) can be prescribed. In humans, esophageal candidiasis can be associated with thrush, which develops in newborns, and they do not always take the disease seriously.

But if the curdled formations from the baby's mouth can be removed mechanically, the fungus from the esophagus can be eliminated only with the help of sufficiently strong medications, which should last for up to two months. And even drug therapy for catarrhal lesions of the esophageal mucosa is effective only in 70% of cases. Therefore, when there are unpleasant sensations when swallowing or the appearance of dyspeptic disorders, you should immediately contact the gastroenterologist.