Erosive esophagitis is visible damage to the lining of your esophagus, the tube that carries food from your throat to your stomach. It occurs when stomach acid repeatedly washes back into the esophagus and breaks down the protective tissue, creating raw, inflamed areas called erosions or mucosal breaks. About 30% of people with gastroesophageal reflux disease (GERD) have erosive esophagitis when examined with a camera scope, making it the more severe end of the reflux spectrum.
How Acid Damages the Esophageal Lining
Your stomach is built to handle acid. Your esophagus is not. When the muscular valve at the bottom of the esophagus (the lower esophageal sphincter) weakens or relaxes too often, acidic stomach contents flow upward and make contact with tissue that has no real defense against it.
For a long time, doctors assumed acid simply burned the surface on contact, like a chemical splash. More recent research has shifted that picture. Acid exposure triggers the cells lining the esophagus to release inflammatory signals, which recruit immune cells into the tissue. The resulting inflammation, driven from within the esophageal wall itself, is what produces the erosions visible during an endoscopy. This means the damage is partly a chemical injury and partly your body’s own inflammatory response to that injury.
The majority of GERD patients actually have non-erosive reflux disease, where symptoms exist but the lining looks normal on endoscopy. Erosive esophagitis represents the point where the reflux has become frequent or severe enough to cause structural damage you can see.
Common Symptoms
The hallmark symptom is heartburn, a burning sensation behind the breastbone that often worsens after meals or when lying down. Beyond that, erosive esophagitis commonly causes:
- Chest pain that can mimic cardiac pain
- Painful swallowing (odynophagia), especially with hot or acidic foods
- Difficulty swallowing (dysphagia), a sensation of food sticking or moving slowly
- Regurgitation of sour or bitter fluid into the throat
- Globus sensation, a persistent feeling of a lump in the throat
- Chronic cough, hoarseness, or wheezing, particularly at night
Severity of symptoms doesn’t always match the severity of erosions. Some people with significant esophageal damage report only mild heartburn, while others with minimal erosions have intense pain. That disconnect is one reason endoscopy remains essential for grading how serious the condition actually is.
How Doctors Grade the Damage
Erosive esophagitis is diagnosed through an upper endoscopy (EGD), where a thin, flexible camera is passed through the mouth and into the esophagus. The doctor looks for mucosal breaks: red, raw patches where the protective lining has worn away.
The most widely used grading system is the Los Angeles (LA) classification, which divides the damage into four grades based on how extensive those breaks are:
- Grade A: One or more small mucosal breaks, none longer than 5 mm, confined within folds of the esophageal lining
- Grade B: Mucosal breaks longer than 5 mm, but still not connecting across folds
- Grade C: Breaks that extend across folds but involve less than 75% of the esophageal circumference
- Grade D: Breaks covering 75% or more of the circumference
Grades A and B are considered mild to moderate and are the most common. Grades C and D are severe and typically require follow-up endoscopy after treatment to confirm the tissue has healed.
Causes Beyond Acid Reflux
GERD is by far the most common cause, but it’s not the only one. Certain medications can directly damage the esophageal lining if they get stuck or dissolve slowly on the way down. This is called pill-induced esophagitis, and the most frequent culprits include:
- Antibiotics, especially doxycycline and other tetracyclines
- NSAIDs like aspirin, which disrupt the esophagus’s protective barrier
- Bisphosphonates used for osteoporosis, particularly alendronate
- Iron supplements and potassium chloride tablets
These medications cause injury through different mechanisms. Some create a local acid burn because the pill itself is highly acidic. Others, like aspirin, strip away the protective layer that shields the tissue. Taking pills with too little water or lying down immediately after swallowing them raises the risk significantly, because the medication sits in contact with the esophageal wall longer.
Treatment and Healing Timelines
The standard treatment is an 8-week course of a proton pump inhibitor (PPI), which dramatically reduces the amount of acid your stomach produces. This gives the esophageal lining time to repair itself. At 4 weeks, fewer than 80% of patients show complete healing on repeat endoscopy. By 8 weeks, healing rates climb to between 80% and 94%, depending on the severity of the original damage and the specific medication used.
That gap between 4 and 8 weeks matters. If you feel better after a few weeks and stop treatment early, the erosions may not have fully healed even though your symptoms improved. For severe cases (Grades C and D), guidelines recommend a repeat endoscopy after the treatment course to visually confirm that healing is complete.
Lifestyle changes work alongside medication. The American College of Gastroenterology recommends avoiding meals within 2 to 3 hours of bedtime, elevating the head of your bed for nighttime symptoms, and losing weight if you’re overweight. Common dietary triggers include fatty foods, chocolate, carbonated drinks, coffee, citrus, tomatoes, spicy foods, alcohol, and tobacco. Not every trigger affects every person equally, so the practical approach is to identify which ones worsen your symptoms and cut those specifically.
What Happens if It Goes Untreated
Chronic, uncontrolled erosive esophagitis can lead to complications that go well beyond discomfort. The most significant are esophageal strictures and Barrett’s esophagus.
Strictures form through a process that starts with swelling and spasm, which are reversible, and progresses to scar tissue buildup in the esophageal wall. Early fibrosis involves collagen deposits that can still respond to acid-suppression therapy. But when scarring extends through the full thickness of the esophageal wall and into surrounding tissue, it creates a permanent narrowing that makes swallowing increasingly difficult. Peptic strictures are more common in older men with severe reflux, weak sphincter pressure, and hiatal hernias.
Barrett’s esophagus is a condition where the normal lining of the lower esophagus transforms into a different type of tissue, one that resembles the intestinal lining. In a community-based follow-up study, erosive esophagitis progressed to Barrett’s esophagus at a rate of about 10 per 1,000 person-years. Barrett’s itself carries a small but real risk of developing into esophageal cancer over time, which is why doctors monitor it with periodic endoscopies.
Schatzki rings, a specific type of narrowing at the junction of the esophagus and stomach, are almost always associated with hiatal hernias and can progress into full peptic strictures if the underlying reflux isn’t controlled.
Erosive vs. Non-Erosive Reflux Disease
If you have reflux symptoms but your endoscopy comes back normal, you have non-erosive reflux disease (NERD), which is actually more common than the erosive form. The two conditions share symptoms, but they differ in important ways. Erosive esophagitis has visible tissue damage that can be graded and tracked. NERD, despite causing real and sometimes severe symptoms, shows a normal-looking esophagus on camera. Treatment overlaps, since both respond to acid suppression, but the healing benchmarks and follow-up strategies differ. With erosive esophagitis, doctors have a concrete visual target: they can see whether the erosions have resolved or worsened, which guides decisions about long-term management.