Radiation-induced esophagitis

Last revised by Andrew Murphy on 23 Mar 2023

Radiation-induced esophagitis is a consequence of radiotherapy toxicity of the esophagus resulting in acute and/or chronic complications: 

  • acute esophagitis: usually 2 to 4 weeks after commencing radiotherapy 1 to within ≤3 months after completion of the radiotherapy 3
  • chronic esophagitis: >3 months after completion of the radiotherapy 3

Patients receiving external-beam radiation therapy to treat bronchogenic carcinoma, mediastinal lymphomas, or tumors involving the thoracic spine are at risk 1. The method of radiation delivery (e.g. conventional radiotherapy vs. 3D-CRT), the total radiation dose, and the concurrent administration of chemotherapy are variants that may increase the risk for radiation-induced esophagitis 2. Simultaneous treatment with doxorubicin hydrochloride greatly accentuates esophageal inflammation 4

  • acute: dysphasia, odynophagia, and chest pain 1,2
  • chronic: pending

The radiation is known to cause cell death via pro-inflammatory cytokines triggered by direct DNA damage. The esophageal mucosa has a high cell turnover and, therefore, is extremely vulnerable to radiation 3. The acute toxicity will manifest as mucosal inflammation, which may complicate with further ulceration or superimposed infection 2.  If the inflammation overtakes the capacity of repair of the mucosa, esophageal fibrosis will progressively develop and manifest later with strictures

Given the superficial involvement in acute radiation-induced esophagitis, most of the cases will show a normal esophagogram. When there is a severe acute esophagitis, fluoroscopy findings may include 1:

  • abnormal peristalsis 2
  • serrated contour due to wall edema
  • granular appearance without discrete ulcers 
  • mucosal ulceration: multiple, small, and within the radiation portal
  • sloughing of the mucosa
  • focal luminal narrowing: due to spasm and edema
  • perforation or fistulation: rare

In the late phase, a radiation-induced stricture may be demonstrated, characterized by a long stenotic segment of smooth contours correlating with the radiation portal 2

Both acute or chronic phases may show a focal esophageal wall thickening along the irradiated esophagus 2

In the acute phase, FDG PET-CT will demonstrate an extensive linear uptake within the irradiated esophagus 2, reflecting inflammation. 

Most of the acute radiation-induced esophagitis tends to be self-limiting in most cases and managed clinically without further investigations 1

Severe cases of acute esophagitis can potentially complicate with perforation or fistulation, but these are rare findings nowadays.  

In the acute phase, consider:

ADVERTISEMENT: Supporters see fewer/no ads