Erosive esophagitis is characterized by visible tissue damage in the lining of the esophagus, the muscular tube connecting the throat to the stomach. This damage manifests as erosions, which are superficial breaks or ulcers in the protective mucosal layer. It is considered a severe form of gastroesophageal reflux disease (GERD), a chronic condition where stomach contents flow back up into the esophagus. Unlike less severe forms of GERD, erosive esophagitis requires the backflow of acid to be persistent and strong enough to cause these visible lesions.
How Erosive Esophagitis Develops
The mechanism behind erosive esophagitis centers on a failure of the lower esophageal sphincter (LES), a ring of muscle at the junction of the esophagus and the stomach. Normally, the LES acts as a one-way valve, closing tightly to prevent stomach contents from backing up. In this condition, the LES either weakens or relaxes inappropriately, allowing stomach acid, pepsin, and sometimes bile to repeatedly enter the esophageal tube.
The esophageal lining is much more delicate than the stomach lining, which is built to withstand high acidity. Chronic exposure to this harsh acidic environment irritates the tissue, leading to inflammation known as esophagitis. Over time, this inflammation progresses to cause the physical erosions and ulcerations that define the condition. Risk factors increase the frequency and severity of acid reflux, including obesity, which increases intra-abdominal pressure, and the presence of a hiatal hernia. Lifestyle factors like smoking, regular alcohol consumption, and consuming large, fatty, or acidic meals also contribute to the weakening of the LES.
Identifying Common Signs
The most frequent sign of erosive esophagitis is persistent heartburn, medically termed pyrosis, which is described as a burning sensation in the chest often rising toward the throat. This symptom frequently worsens after eating or when lying down. Another common complaint is regurgitation, where stomach contents or a sour, bitter liquid flow back into the throat or mouth.
The damage to the tissue also leads to difficulties with swallowing (dysphagia), which may feel like food getting stuck in the esophagus. Patients may also experience odynophagia, which is pain specifically triggered by swallowing food or liquids due to passage over the irritated tissue. Less common, but serious, signs include unexplained chronic cough, hoarseness, and in advanced cases, visible blood in vomit or dark, tarry stools, indicating bleeding from the erosions.
Diagnosing the Severity
Confirmation and assessment of erosive esophagitis require a direct visual examination using an upper endoscopy, also known as esophagogastroduodenoscopy (EGD). During this procedure, a flexible tube equipped with a light and camera is passed down the throat into the esophagus and stomach. This allows the physician to clearly view the mucosal lining and document any damage, providing objective evidence of the erosions that define the condition.
The severity of the tissue damage is standardized using the Los Angeles (LA) Classification System, which categorizes the extent of the mucosal breaks into four grades (A, B, C, and D). Grade A is the mildest, consisting of one or more breaks no longer than five millimeters that do not extend between the tops of two mucosal folds. Grade B involves breaks longer than five millimeters, but they still do not connect across the folds.
The more severe grades involve breaks that become confluent, meaning they merge together. Grade C is defined by mucosal breaks that extend between the tops of two or more mucosal folds, but the damage covers less than 75% of the esophageal circumference. Grade D, the most severe category, is characterized by confluent mucosal breaks that involve at least 75% of the circumference. The LA grade confirms the diagnosis and directly informs the intensity and duration of the treatment plan. A biopsy may also be taken during the endoscopy to rule out other causes of inflammation or to check for cellular changes.
Healing Strategies and Long-Term Protection
The primary goal of managing erosive esophagitis is to promote healing of the damaged tissue by reducing stomach acid production. Proton Pump Inhibitors (PPIs) are the first-line medical treatment, working by irreversibly blocking the proton pumps in the stomach lining that produce acid. This powerful reduction in acid allows the esophageal erosions to heal, with studies showing healing rates in the range of 75% to 95% after an eight-week course of therapy.
H2 blockers may be used for milder cases or in combination with PPIs, as they work by blocking histamine receptors that stimulate acid secretion. However, H2 blockers are less effective at healing erosions compared to PPIs.
Medication is often paired with lifestyle adjustments, which are fundamental for long-term protection and preventing recurrence. These changes include elevating the head of the bed by six to eight inches to use gravity to minimize nighttime reflux, and avoiding meals close to bedtime.
Dietary modifications are also crucial, focusing on reducing or eliminating trigger foods like high-fat items, chocolate, caffeine, and acidic juices, which can weaken the LES or irritate the esophagus. For patients who are overweight, weight loss is recommended, as it decreases the abdominal pressure that forces stomach contents upward.
If erosive esophagitis is poorly managed, chronic inflammation can lead to serious complications. Repeated damage and healing can cause scar tissue to form, resulting in esophageal strictures, a narrowing of the tube that makes swallowing difficult. There is also a risk of developing Barrett’s Esophagus, a condition where the normal esophageal lining is replaced by intestinal-like cells, which carries an increased risk of developing esophageal cancer.