Summary of treatent of Herpetic esophagitis

1. HSV esophagitis {HE}
Ahmed Mohamed Badheeb
Prof Of Oncology & Internal Medicine

4. Management
• Treatment includes the following components:
• Hemodynamic stabilization (eg, in cases of bleeding or perforation)
• Pain management – Because chest pain of esophageal origin cannot
be accurately differentiated from chest pain associated with CAD,
prehospital protocols for the latter should be followed
• Specific therapy, depending on the cause of the esophagitis and any
complications
• Treatment of reflux esophagitis may include the following:
• Histamine-2 receptor antagonists (H2RAs)
• Proton pump inhibitors (PPIs)
• Cisapride (a gastroprokinetic agent)
• Sucralfate (a coating agent)

5. Management
• Although HE may resolve spontaneously, in
immunocompetent but also in
immunodepressed patients , antiviral
treatment is always indicated to prevent the
diffusion of the infection, and/or to limit the
risk of dehydration, malnutrition and local
sequelae.

6. The treatment of choice for HE
• Acyclovir remains the treatment of choice for HE, although
very few controlled studies are available.
• Oral administration seems as efficient as the intravenous
route, but is frequently impossible because of dysphagia,
odynophagia and vomiting.
• 800 mg PO q4hr while awake (5 times daily) for 7-10 days
• Intravenous administration (15 mg/kg/day or 250
mg/m2/day) is usually rapidly effective in solid organ
transplant recipients , AIDS patients or marrow transplant
recipients .

7. Treatment failure
• In immunodepressed patients, treatment
failure may be explained by esophageal co-
infections or other esophageal disease

8. Acyclovir-resistant mucocutaneous
herpes infections
• Some HE may be due to acyclovir-resistant
viral strains , more frequently in patients who
have been repeatedly exposed to this drug .
Such cases should be treated with foscarnet ,
which is superior to vidarabine for acyclovir-
resistant mucocutaneous herpes infections in
AIDS .

9. Primary prophylactic acyclovir
treatment
• Primary prophylactic acyclovir treatment can
be considered in high-risk immunodepressed
patients, but not in AIDS patients. Indeed,
when given 3 days before bone marrow
transplantation, it prevented HSV reactivation
and reduced the incidence of HSV infections
from 50–80% to less than 10% .

10. Prophylactic acyclovir
• In AIDS, HE recurrences are uncommon and
suppressive therapy should not be
systematically prescribed. However, in cases of
frequent or severe recurrences, a preventive
regimen (600–1000 mg in 3–5 divided oral
doses per day) may be administered.

11. HSV esophagitis
• Acyclovir
• foscarnet (for acyclovir-resistant cases),
or
• famciclovir

12. Management
• Antiviral Agents
• Antiviral agents are used to treat herpes
simplex virus (HSV) or cytomegalovirus (CMV)
infections. In addition to the drugs listed
below, famciclovir (Famvir), a prodrug of the
antiviral agent penciclovir, which is not
currently recommended for treatment, may
replace acyclovir in prophylaxis and
treatment.

13. Acyclovir (Zovirax)
• Acyclovir is a synthetic purine nucleoside
analog that stops replication of viral DNA. It is
used to treat HSV esophagitis.

14. Foscarnet (Foscavir)
• Foscarnet is an organic analog of inorganic
pyrophosphate that inhibits replication of HSV
and CMV. It is used to treat acyclovir-resistant
cases.

15. Ganciclovir (Cytovene)
• Ganciclovir is an acyclic nucleoside analog that
inhibits replication of herpes viruses. It is
active against CMV and HSV.

16. Famciclovir (Famvir)
• Famciclovir is goes through biotransformation
to active penciclovir. Penciclovir has inhibitory
activity against varicella-zoster virus (VZV) and
herpes simplex virus types 1 and 2. It may be
used for herpes and VZV esophagitis.

17. CONCLUSION
• HE is common in immunocompromised patients and should
be systematically suspected in cases of odynophagia, chest
pain, unexplained nausea or upper digestive tract bleeding.
Most of the time, HE results from HSV-1 reactivation and
the regional extension of an oral or pulmonary infection.
Diagnosis is suggested through endoscopy, which usually
displays ulcerated esophagitis predominantly in the lower
third. The combination of brush cytology, histology and
viral cultures allows the best diagnostic sensitivity.
Empirical acyclovir treatment also allows a presumptive
diagnosis when it is rapidly effective. Finally, HE most often
presents as a benign condition when it is diagnosed early
and treated.

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