Candida esophagitis is an infection of the esophagus, the muscular tube that carries food and liquid from the mouth to the stomach, caused by a yeast called Candida. The infection produces inflammation and damage to the lining of the esophagus. It is also called esophageal candidiasis or esophageal thrush, and it is the most common infection of the esophagus.
An important point comes first. Candida normally lives harmlessly in the mouth, throat, and digestive tract of most healthy people. Its presence alone is not an infection. Candida esophagitis is diagnosed when the yeast has stopped behaving as a harmless resident and has begun growing into the surface lining of the esophagus. This is why a biopsy matters: the pathologist looks not simply for the organism, but for evidence that it is invading the tissue.
Candida esophagitis is treatable and usually clears completely with antifungal medication. It also carries a second piece of information: because it takes hold when the body’s defenses are reduced, the diagnosis is often a signal to look for an underlying reason. This article will help you understand the findings in your pathology report, what each term means, and why it matters for your care.
Candida esophagitis develops when Candida yeast, normally kept in check by the immune system, competing bacteria, stomach acid, and the constant sweeping motion of swallowing, is able to overgrow and invade the lining of the esophagus. Anything that weakens one of those defenses can allow it to happen.
The species responsible is usually Candida albicans. Less commonly, other species such as Candida glabrata or Candida krusei are involved, and these matter because they respond less reliably to the standard antifungal drug.
Conditions and treatments that increase the risk include:
Not everyone with this infection has a serious underlying illness. It occurs in people with no identifiable risk factor at all, and inhaled steroid use is a common and entirely benign explanation. Where no cause is apparent, however, testing for HIV is usually offered, because esophageal candidiasis can be the first sign of undiagnosed HIV infection and finding it early makes a substantial difference to treatment.
The most characteristic symptom of Candida esophagitis is pain on swallowing, called odynophagia, which distinguishes it from most other esophageal conditions. Difficulty swallowing and a sensation of food sticking are also common, as are chest discomfort behind the breastbone, nausea, and reduced appetite.
Oral thrush, appearing as white patches on the tongue and inside the cheeks, is present in many but not all people with esophageal infection. Its absence does not rule out the diagnosis, and its presence does not confirm it, since the esophagus can be involved without the mouth and the reverse is also true.
Some people have no symptoms at all, and the infection is found incidentally during an endoscopy performed for another reason. This is more common in people whose immune system is significantly suppressed.
Candida esophagitis is diagnosed during an upper endoscopy, in which a thin flexible tube with a camera is passed through the mouth to examine the lining of the esophagus. The infection has a characteristic appearance: creamy white or yellowish patches, called plaques, stuck to the surface of the lining. Unlike food debris, these do not wash away, and the lining underneath is often red and raw. Endoscopists sometimes grade the extent from a few scattered plaques to a thick continuous coating with narrowing of the esophagus.
The appearance is suggestive but not conclusive on its own, so samples are usually taken. These may be brushings, in which the surface is swept with a small brush, or biopsies, in which small pieces of tissue are removed. Both are sent to a pathologist for examination under a microscope. A biopsy has an advantage over a brushing: because Candida lives normally in the mouth and throat, a brushing can pick up organisms that were simply passing through, while a biopsy shows whether the yeast is actually growing into the tissue.
Biopsies are also taken to look for the other infections that can affect the esophagus, since more than one can be present at the same time, and to check for other explanations of the symptoms.
When tissue from a person with Candida esophagitis is examined under the microscope, the pathologist looks for the organism itself and for the tissue’s response to it. Findings that may appear on your report include:
Your report may describe the organisms as “fungal organisms morphologically consistent with Candida species” rather than naming the species outright. This is accurate rather than evasive: the different Candida species look essentially identical under the microscope and can only be told apart by culture or molecular testing, which is not usually needed unless the infection fails to respond to treatment.
Candida can be difficult to see on a routine tissue stain, particularly when there are few organisms or when heavy inflammation obscures them. To make them stand out, the pathologist may apply a special stain, a chemical treatment that colors specific substances in the tissue. Two are commonly used, and either may be named on your report:
These stains show where the organisms are and what shape they take, which is how invasion is confirmed. They do not identify which species is present. A report that does not mention a special stain is not incomplete; the stains are used when the organisms are hard to see, and are unnecessary when they are obvious.
Candida is the most common cause of infectious esophagitis, but it is not the only one, and part of the reason biopsies are examined carefully is to identify the others. This matters because they are treated with entirely different medications, and because more than one infection can be present at once in someone whose immune system is suppressed.
The outlook for Candida esophagitis is very good. With appropriate antifungal treatment, the infection clears completely in the large majority of people; symptoms usually begin to improve within a few days, and the lining of the esophagus heals without lasting damage.
Complications are uncommon and occur mainly when the infection is severe, when treatment is delayed, or when the immune system is profoundly suppressed. They include bleeding from an ulcer, narrowing of the esophagus from scarring, and, rarely, spread of the infection beyond the esophagus.
The most common problem is not complication but recurrence, and this depends largely on whether the underlying cause can be addressed. Someone whose infection followed a course of antibiotics or inhaled steroid use is unlikely to have it again once that is corrected. Someone with ongoing immune suppression may have repeated episodes, and preventive treatment can be considered in that situation.
Candida esophagitis is treated with antifungal medication taken throughout the body rather than applied to the mouth, because lozenges and rinses used for oral thrush do not reach the esophagus in adequate amounts.
Fluconazole taken by mouth is the standard treatment, given for about two to three weeks. When swallowing is too painful to take tablets, the same drug can be given through a vein. Most people notice improvement within the first few days, and completing the full course matters even after symptoms settle, since stopping early allows the infection to return.
If the infection does not improve as expected, a culture may be performed to identify the species and test which drugs it responds to. Some species are naturally less susceptible to fluconazole, and Candida albicans can acquire resistance after repeated exposure. Alternative antifungal drugs, including the echinocandin class given intravenously, are effective in these situations.
Alongside treating the infection, attention turns to why it occurred. This may involve reviewing current medications, improving blood sugar control, and checking inhaled steroid technique, since rinsing the mouth and spitting after each dose substantially reduces the risk. Where no explanation is apparent, testing for HIV is generally offered. For people with ongoing immune suppression and repeated episodes, low-dose antifungal medication taken regularly can be used to prevent recurrence, and for those with HIV, effective antiretroviral treatment is the most important measure.
A repeat endoscopy is not usually needed once symptoms have resolved. It may be arranged if symptoms persist, if the infection was unusually severe, or if there is a reason to look again at the esophagus.