Oesophageal candidiasis (thrush of the gullet): symptoms, causes and treatment

The oesophagus is the muscular tube that carries food and drink from the throat to the stomach. In oesophageal candidiasis, Candida yeast, most often Candida albicans, grows in the lining of that tube and causes inflammation. It is sometimes called Candida oesophagitis or thrush of the gullet.

NICE CKS explains that Candida lives quietly in the digestive tract of most people without causing trouble, and that infections range from mild surface problems to invasive disease affecting several organs. Oesophageal candidiasis sits in the middle of that spectrum: more extensive than a patch of oral thrush, but usually confined to the gullet.

It is different from acid reflux, which can also cause pain behind the breastbone. The two can look similar from the symptoms alone, which is one reason an examination with a camera may be needed to tell them apart.

Patient.info’s professional article describes the typical picture as difficulty swallowing, pain when swallowing food or fluids, and pain behind the breastbone, usually accompanied by thrush in the mouth or throat. It notes that this combination of symptoms is predictive of oesophageal candidiasis.

White patches on the tongue, inside the cheeks or at the back of the throat may be visible, although not everyone has them. Food may feel as if it is sticking, and some people eat less because swallowing hurts.

• Pain or discomfort on swallowing food, drink or even saliva.

• A sensation of food catching on the way down.

• Pain or burning behind the breastbone.

• White coating or patches in the mouth or throat alongside swallowing problems.

• Loss of appetite or weight loss because eating has become painful.

Painful or difficult swallowing should not be left to settle by itself, particularly if it is getting worse, if you are losing weight, or if you have a condition or take medicines that weaken your immune system. A GP or NHS 111 can advise on how quickly to be seen.

NICE CKS says hospital admission should be arranged when oesophageal candidiasis is suspected or the person is systemically unwell, and Patient.info states that the infection can be life-threatening in some people. If you cannot swallow fluids or feel very unwell, treat that as urgent and contact NHS 111 or, if it is an emergency, call 999.

The infection is an opportunistic one: the yeast takes advantage of a change in the body. NICE CKS lists diabetes, severe anaemia and immune suppression, for example from chemotherapy, radiotherapy, HIV infection or AIDS, among the conditions that increase the risk of candidal infection. It also names poor dental hygiene, local trauma, smoking, broad-spectrum antibiotics, inhaled or oral corticosteroids and malnutrition.

Patient.info adds central venous catheters or parenteral nutrition, Cushing’s disease, renal replacement therapy, implanted prostheses, intensive care or prolonged ventilation and surgery on the gastrointestinal tract to its list of risk factors for candidal infection in general. For the oesophagus specifically, it says the infection is most often associated with treatment of blood or lymphatic cancers and that in people with HIV it is an AIDS-defining illness.

In practical terms this means the finding of oesophageal candidiasis often prompts a wider review: medicines, blood sugar, immune function and, where appropriate, HIV testing.

A doctor will ask about swallowing, medicines (especially steroid inhalers or tablets and antibiotics), existing conditions and anything that may have lowered immunity. They will look in the mouth for thrush.

Patient.info says that a therapeutic trial of fluconazole is useful and that most people respond within 7 days, but that the definitive diagnosis is made by endoscopy. In an endoscopy (gastroscopy) a thin flexible camera is passed through the mouth into the gullet, and the doctor can see the characteristic patches and take a small tissue sample if needed. Blood tests may be arranged to look for causes such as diabetes or reduced immunity.

Patient.info says treatment is usually advised by secondary care and that it should last 14 to 21 days. Antifungal medicines are used because the infection is in the tissue lining the gullet, so topical mouth gels are not enough on their own.

NICE CKS recommends oral fluconazole for adults when oral thrush is extensive, severe or the person is significantly immunocompromised, and the same medicine family is the usual choice for the oesophagus.

For most people the infection responds to antifungal treatment and swallowing returns to normal. If it does not improve, or if it keeps coming back, doctors look again for an underlying cause and may arrange specialist advice. NICE CKS advises referral for recurrent episodes of candidiasis, for breakthrough infection while taking preventive treatment (which may point to resistance) and where there is doubt about the diagnosis.

Prevention centres on the underlying trigger: good control of diabetes, careful use of inhaled steroids (using a spacer and rinsing the mouth afterwards is standard advice for oral thrush), not smoking, and reviewing long-term antibiotics or steroids with the prescriber. Never stop a prescribed medicine without asking.

Because the infection is usually found alongside another health problem, most people are looked after through an NHS GP and hospital gastroenterology or infectious diseases team, with endoscopy done as a day-case procedure.

Some people use private endoscopy services to be seen sooner; the test and the treatment are the same. Whichever route you use, make sure the results and any underlying cause are shared with your GP so that follow-up is coordinated.