Erosive Oesophagitis

Erosive oesophagitis is a condition where the lining of the esophagus becomes damaged and worn away due to repeated exposure to stomach acid, leading to inflammation, painful swallowing, and potentially serious complications if left untreated.

Table of contents

• What is Erosive Oesophagitis?
• Causes and Risk Factors
• Symptoms
• How is it Diagnosed?
• Possible Complications
• Treatment Options
• Diet and Lifestyle Changes

What is Erosive Oesophagitis?

Erosive oesophagitis is erosion of the esophageal epithelium (the protective lining of the food pipe) due to chronic irritation^[1]. The esophagus is the muscular tube that carries food and drink from your throat down to your stomach^[2]. When this lining is repeatedly exposed to stomach acid, it becomes damaged, leading to inflammation, wounds, and discomfort^[3].

This condition is the most common complication of gastroesophageal reflux disease (GERD), a disorder where stomach contents flow backward into the esophagus^[4]. Erosive oesophagitis occurs in approximately 30% of cases of GERD and affects an estimated 1% of the general population^[5]. It is characterized by excessive reflux that leads to necrosis (tissue death) of the esophageal lining, erosions, ulcerations, and in severe cases, hemorrhage (bleeding)^[6].

• Esophagus
• Lower esophageal sphincter
• Stomach

Causes and Risk Factors

The primary cause of erosive oesophagitis is injury to the esophagus from gastric acid and pepsin, leading to symptoms and esophageal damage when the pH level drops below 4^[7]. Several factors can contribute to the development of this condition.

GERD is the main risk factor for erosive oesophagitis, but it is not the only one^[8]. When the lower esophageal sphincter (a muscular valve at the bottom of the esophagus) becomes defective, it fails to prevent stomach contents from flowing back into the esophagus^[9]. The presence of a hiatal hernia (when part of the stomach pushes through the diaphragm) can cause abnormal esophageal clearance and contribute to the development of erosive oesophagitis^[10].

Other risk factors include radiation therapy toxicity, which can cause acute or chronic erosive oesophagitis^[11]. For individuals undergoing radiotherapy, radiation esophagitis is a relatively frequent complication, with acute esophagitis generally occurring in all patients taking radiation doses of 6000 cGy given in fractions of 1000 cGy per week^[12].

Bacterial, viral, and fungal infections can also cause erosive oesophagitis, including infections such as herpes, CMV, HIV, Helicobacter pylori, and Candida^[13]. Oral medications in pill form can cause esophagitis at an estimated rate of 3.9 cases per 100,000 population per year^[14]. Oral bisphosphonates such as alendronate are the most common agents, along with antibiotics such as tetracycline, doxycycline, and clindamycin^[15]. NSAIDs, aspirin, ferrous sulfate, potassium chloride, and mexiletine have also been reported as causes of pill-induced esophagitis^[16].

Food allergies, asthma, and eczema are associated with eosinophilic esophagitis, which disproportionately affects young men^[17]. Excessive vomiting can, in rare cases, cause esophagitis, and certain autoimmune diseases can manifest as erosive oesophagitis^[18].

Symptoms

The main symptoms of erosive oesophagitis are heartburn and regurgitation^[1]. Heartburn is a constant burning sensation in the chest, usually worse after eating^[2]. Other common symptoms include painful swallowing, which is sharp pain when eating or drinking, and dysphagia (difficulty swallowing), caused by inflammation or narrowing of the esophagus^[3].

Additional symptoms can include epigastric pain (pain in the upper abdomen), odynophagia (painful swallowing), nausea, chronic cough, dental erosion, laryngitis, and asthma^[4]. Patients may also experience the feeling of acidic food or liquid returning to the throat or mouth, food getting stuck in the esophagus, and prolonged abdominal discomfort^[5].

In severe cases, bleeding can occur, with blood visible in vomit or stool^[6]. The pain associated with erosive oesophagitis may be mild to severe and can be constant or come and go^[7]. Symptoms can be exacerbated by eating certain trigger foods or when lying down^[8].

In babies and young children with esophagitis who are too young to explain their discomfort or pain, symptoms can include feeding troubles, such as getting easily upset, arching of the back, and not wanting to eat, as well as failure to gain weight (failure to thrive)^[9]. Identifying these symptoms early can help a person receive appropriate treatment and prevent further damage to the esophagus^[10].

How is it Diagnosed?

Diagnosis of erosive oesophagitis requires testing to differentiate it from other manifestations of GERD, including nonerosive esophagitis and Barrett’s esophagus^[1]. Your healthcare professional will ask about your symptoms and perform a physical examination^[2].

Endoscopy is a test that’s used to check the digestive system and is the primary diagnostic tool for erosive oesophagitis^[3]. During this procedure, a healthcare professional guides a long, thin tube equipped with a tiny camera, called an endoscope, down the throat and into the esophagus^[4]. The endoscope allows the doctor to see if the esophagus looks different than usual, and small tissue samples may be taken for testing in a process called a biopsy^[5]. Before this test, you receive medicine that helps you relax^[6].

The esophagus may look different depending on the cause of the swelling, such as medicine-induced or reflux esophagitis^[7]. An esophageal capsule test can be done in the healthcare professional’s office, involving swallowing a capsule attached to a string that helps sample the esophageal tissues^[8].

A barium X-ray involves drinking a solution or taking a pill that contains a compound that coats the esophagus, allowing X-ray images to reveal abnormalities^[9]. These diagnostic tests help determine the severity of erosive oesophagitis and guide treatment decisions.

Possible Complications

Erosive oesophagitis can cause serious consequences if left untreated^[1]. The complications include esophageal scarring or stricture formation, where healthy esophageal tissue is replaced by fibrous tissue^[2]. This can impair the functioning of the esophagus due to stiffening or narrowing^[3].

Narrowing of the esophagus may impair the passage of food from the mouth to the stomach, causing problems such as difficulty swallowing and consequent malnutrition^[4]. When food does not pass through the esophagus due to narrowing or strictures, it may find its way back to the mouth and throat, from where it may enter the respiratory tract in a process called aspiration^[5]. This can cause inflammation of the lungs known as aspiration pneumonitis^[6].

Refluxed food can irritate the throat, causing inflammation called laryngitis^[7]. Untreated erosive oesophagitis may cause changes in the lining of the esophagus known as Barrett’s esophagus, a condition that increases the risk of esophageal cancer^[8]. Erosive oesophagitis may evolve to Barrett’s esophagus in 1% to 13% of cases^[9].

Inflamed and worn-out areas are at risk of bleeding and developing holes or tears, known as perforation, in the esophageal wall^[10]. Without treatment, erosive oesophagitis can damage the esophageal lining and may start to have trouble moving food and liquid from the mouth to the stomach^[11]. Other serious complications include scarring or narrowing of the esophagus, unhealthy weight loss, and dehydration^[12].

Treatment Options

The future of erosive oesophagitis management lies in a more personalized approach that takes into account disease severity, response to treatment, and patient preferences^[1]. Long-term management focuses on relieving symptoms to allow the esophageal lining to heal, thereby reducing both acute symptoms and the risk for other complications^[2].

Proton pump inhibitors (PPIs) are the preferred treatment both in the acute setting and for maintenance therapy^[3]. PPIs help to alleviate symptoms and promote healing of the esophageal lining by reducing the production of stomach acid^[4]. Options include omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole^[5]. Research has shown that PPIs remain the most effective treatment, achieving healing rates of 75% to 95% after 8 weeks, though symptom resolution reaches about 60% to 85%^[6].

Many patients with erosive oesophagitis require a dose that exceeds the FDA-approved dose for GERD^[7]. For instance, a 40-mg daily dosage of omeprazole is recommended in the latest guidelines, although the FDA-approved dosage is 20 mg daily^[8]. Among PPIs, esomeprazole shows slightly better healing outcomes compared to others^[9]. However, PPI effectiveness decreases in advanced erosive oesophagitis cases, with healing rates dropping to 60% to 70%^[10].

H2-receptor antagonists, including famotidine, cimetidine, and nizatidine, may also be prescribed to reduce stomach acid production and promote healing in patients with erosive oesophagitis due to GERD, but these agents are considered less efficacious than PPIs for either acute or maintenance therapy^[11].

The potassium-competitive acid blocker (PCAB) vonoprazan is the latest agent to be indicated for erosive oesophagitis and may provide more potent acid suppression for patients^[12]. More recently, P-CABs have demonstrated promising results, demonstrating healing rates non-inferior to PPIs but superior in patients with advanced erosive oesophagitis or PPI-resistant erosive oesophagitis^[13]. A randomized comparative trial showed noninferiority compared with lansoprazole for healing and maintenance of healing of erosive oesophagitis^[14].

Mild GERD symptoms can be controlled by traditional antacids taken after each meal and at bedtime or with short-term use of prokinetic agents, which can help reduce acid reflux by improving esophageal and stomach motility^[15]. Long-term use of prokinetic agents is discouraged, as it may cause serious or life-threatening complications^[16].

In patients who do not fully respond to PPI therapy, surgical therapy may be considered^[17]. Other candidates for surgery include younger patients, those who have difficulty adhering to treatment, postmenopausal women with osteoporosis, patients with cardiac conduction defects, and those for whom the cost of treatment is prohibitive^[18]. Given that most patients experience relapse upon discontinuation, maintaining PPI or PCAB therapy is crucial for preventing erosive oesophagitis recurrence^[19].

Diet and Lifestyle Changes

Management plans may incorporate lifestyle changes, such as dietary modifications and weight loss, alongside pharmacologic therapy^[1]. Eating the right foods can help relieve esophageal symptoms and prevent flare-ups^[2].

Foods to avoid include acidic items such as tomatoes, citrus fruits, and products made from vinegar; spicy food such as chili peppers and spicy sauces; foods high in fat such as fried foods, fatty meats, and full-fat dairy products; caffeinated and carbonated drinks such as coffee, soda, and energy drinks; and candies such as chocolate and peppermint, which relax the lower esophageal sphincter, making acid reflux worse^[3].

Foods to include are low-acidity fruits such as bananas, melons, and apples; vegetables such as leafy greens, carrots, and broccoli; whole grains such as oats, brown rice, and whole-grain bread; lean protein such as skinless chicken, fish, tofu, and egg whites; and low-fat milk substitutes such as almond milk, soy milk, and low-fat yogurt^[4].

Important dietary habits include eating small, frequent meals to reduce pressure on your stomach, not lying down for at least 2 to 3 hours after eating, and chewing your food slowly and thoroughly to help digest food^[5].

Lifestyle changes play an important role in managing symptoms and preventing relapse^[6]. Keep your head elevated while sleeping by using a wedge pillow or raising the bed 6 to 8 inches to help reduce acid reflux at night^[7]. Maintaining a healthy weight is important, as excessive weight increases intra-abdominal pressure (the pressure in your stomach cavity) and increases reflux^[8]. Combine a balanced diet with low-impact exercise such as walking or swimming^[9].

Avoid smoking and alcohol, as smoking weakens the lower esophageal sphincter and may increase the risk of acid exposure, while alcohol stimulates the esophagus and increases acid production^[10]. Stress management through practices such as mindfulness, meditation, or yoga can reduce reflux symptoms^[11]. Wear loose clothing, as belts and clothing that are tight around the abdomen can make acid reflux problems worse^[12]. These lifestyle changes can greatly improve symptoms and quality of life for people living with erosive oesophagitis.