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Erosive Esophagitis

What is Erosive Esophagitis?

Erosive esophagitis (EE) is an inflammation of the lining of the esophagus that has caused visible breaks or “erosions” in the mucosal surface. It is the most severe form of gastro‑esophageal reflux disease (GERD) and is usually diagnosed when an endoscope shows (1) erythema, erosions, ulcerations, or (2) longer, deeper lesions that extend into the sub‑mucosa. The condition can lead to pain, bleeding, and, if untreated, strictures (narrowing) or Barrett’s esophagus, a precancerous change.

Unlike non‑erosive reflux disease, which may cause heartburn without visible injury, EE is an objective finding that often correlates with more intense reflux symptoms and a higher risk of complications.

Common Causes

Most cases of erosive esophagitis are related to chronic exposure of the esophageal lining to acidic or otherwise irritating contents. The main contributors include:

• Gastro‑esophageal reflux disease (GERD): Persistent backflow of stomach acid and digestive enzymes.
• Hiatal hernia: Displacement of part of the stomach into the chest cavity reduces the competence of the lower esophageal sphincter.
• Pill‑induced esophagitis: Certain medications (e.g., NSAIDs, tetracyclines, bisphosphonates, potassium chloride) can irritate the mucosa if not taken with enough water.
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• Alcohol consumption: Alcohol lowers sphincter tone and directly damages the mucosa.
• Cigarette smoking: Nicotine relaxes the lower esophageal sphincter and impairs mucosal healing.
• Obesity: Increased intra‑abdominal pressure promotes reflux.
• Delayed gastric emptying (gastroparesis): Stomach contents stay longer, increasing reflux risk.
• Infections: Candida, herpes simplex, or cytomegalovirus in immunocompromised patients can cause erosive lesions.
• Autoimmune or eosinophilic esophagitis: Inflammatory disorders that weaken the barrier function of the esophageal lining.
• Radiation therapy to the chest: Direct injury to the esophageal mucosa.

Associated Symptoms

The irritation and ulceration of the esophageal lining produce a cluster of typical complaints:

• Burning retrosternal pain (heartburn) that may worsen after meals or when lying down.
• Sour or bitter taste in the mouth, especially in the morning.
• Regurgitation of undigested food or liquid.
• Difficulty swallowing (dysphagia) or sensation of food sticking.
• Odynophagia – painful swallowing.
• Chest pain that can mimic angina; often described as a “tight band” feeling.
• Chronic cough, hoarseness, or throat clearing (due to micro‑aspiration).
• Unexplained weight loss (if swallowing becomes painful).
• Occasional vomiting of blood (hematemesis) or black, tar‑like stools (melena) if bleeding occurs.

When to See a Doctor

While occasional heartburn is common, the following situations warrant prompt medical evaluation:

• Heartburn or regurgitation that occurs ≥ 3 times per week or persists for more than 2 weeks despite over‑the‑counter antacids.
• New‑onset difficulty swallowing or pain when swallowing.
• Unintended weight loss or loss of appetite.
• Vomiting blood, coffee‑ground material, or passing black stools.
• Chest pain that does not improve with antacids or is associated with shortness of breath, sweating, or radiating pain to the arm/jaw – rule out cardiac causes first.
• Chronic cough, hoarseness, or recurrent sore throat unresponsive to usual treatments.

Diagnosis

Diagnosis of erosive esophagitis combines a careful history, physical examination, and objective testing. The most widely used tools are:

1. Upper Endoscopy (Esophagogastroduodenoscopy, EGD)

• Considered the gold standard; allows direct visualization of erosions, ulcerations, and strictures.
• Biopsies can be taken to rule out Barrett’s esophagus, eosinophilic esophagitis, or malignancy.

2. Esophageal pH Monitoring

• Quantifies acid exposure over 24‑48 hours; useful when symptoms are atypical or when endoscopy is normal.

3. Manometry

• Measures esophageal motility and lower esophageal sphincter pressure; indicated if dysphagia is prominent.

4. Barium Swallow (Upper GI series)

• Helps identify strictures, hiatal hernia, or motility problems; less sensitive for mucosal erosions but useful if endoscopy is unavailable.

5. Laboratory Tests

• Complete blood count (CBC) for anemia from chronic bleeding.
• Helicobacter pylori testing if peptic ulcer disease is suspected.
• Serology for viral infections in immunocompromised patients.

Treatment Options

Therapy is aimed at reducing acid exposure, healing existing erosions, and preventing recurrence.

Medical Therapy

1. Proton Pump Inhibitors (PPIs): First‑line agents (omeprazole, esomeprazole, lansoprazole, pantoprazole). Standard dose for 8‑12 weeks induces healing in > 90 % of patients.<sup>1</sup>
2. H2‑Receptor Antagonists: Ranitidine, famotidine—useful for mild disease or as adjuncts, but less effective for severe erosions.
3. Protective Agents: Sucralfate forms a protective coating; can be added for ulcer healing.
4. Prokinetics: Metoclopramide or domperidone improve gastric emptying and lower sphincter tone; consider in gastroparesis‑related EE.
5. Alginate‑containing formulations: Gaviscon creates a raft that limits reflux, helpful after meals.
6. Antibiotics/Antivirals: Reserved for infectious etiologies (e.g., Candida – fluconazole; HSV – acyclovir).

Lifestyle & Home Measures

• Elevate the head of the bed 6‑8 inches (use a wedge pillow or riser blocks).
• Avoid eating within 2‑3 hours of bedtime.
• Limit trigger foods and beverages: citrus, tomato‑based sauces, chocolate, peppermint, caffeine, carbonated drinks, fatty/fried foods, and alcohol.
• Maintain a healthy weight; aim for a BMI < 25 kg/m².
• Quit smoking; nicotine reduces lower esophageal sphincter pressure.
• Chew gum after meals (stimulates saliva, neutralizes acid).
• Take prescription medications with a full glass of water, remain upright for at least 30 minutes.

Surgical & Endoscopic Interventions

• Laparoscopic Fundoplication: Nissen or partial fundoplication reconstructs the valve mechanism; considered in refractory GERD/EE or when lifelong medication is undesirable.
• Magnetic Sphincter Augmentation (LINX):** A ring of magnetized beads augments the lower esophageal sphincter.
• Endoscopic Radiofrequency (Stretta) or Endoluminal Suturing: Emerging options for selected patients.
• Endoscopic dilation for strictures that develop after healing.

Prevention Tips

Even after successful treatment, many patients experience recurrence. Implementing long‑term preventive strategies reduces the risk of repeat erosive episodes:

• Adopt a GERD‑friendly diet: small, frequent meals; low‑fat, low‑acid foods.
• Continue weight management programs if overweight.
• Schedule regular follow‑up endoscopy if you have risk factors for Barrett’s esophagus (long‑standing EE, family history).
• Review all medications with your pharmacist; ask about less irritating alternatives.
• Limit night‑time eating and avoid lying down immediately after meals.
• Consider a maintenance dose of a PPI (e.g., half dose daily) if you have frequent relapses, after discussing risks and benefits with your physician.
• Stay hydrated; adequate water intake helps dilute gastric acid.
• Practice good oral hygiene; acidic reflux can erode teeth, prompting more acidic exposures.

Emergency Warning Signs

If any of the following occur, seek emergency medical care (call 911 or go to the nearest emergency department):

• Profuse vomiting of bright red blood or material that looks like coffee grounds.
• Black, tar‑like stools (melena) indicating upper gastrointestinal bleeding.
• Sudden inability to swallow any liquids or foods (complete dysphagia).
• Severe chest pain radiating to the back, arm, or jaw that does not improve with antacids.
• Signs of shock: rapid heartbeat, light‑headedness, pale or clammy skin, confusion.
• Persistent vomiting that leads to dehydration or electrolyte imbalance.

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**References**

1. Mayo Clinic. Gastroesophageal reflux disease (GERD). 2023. https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940
2. American College of Gastroenterology. ACG Clinical Guideline: Diagnosis and Management of GERD. 2022. https://gi.org/guideline/gerd/
3. Cleveland Clinic. Erosive Esophagitis. 2024. https://my.clevelandclinic.org/health/diseases/21085-erosive-esophagitis
4. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). GER & Esophageal Reflux. 2023. https://www.niddk.nih.gov/health-information/digestive-diseases/gerd
5. World Health Organization. Guidelines for the Management of Reflux Disease. 2022.

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