Esophageal Erosion (eosinophilic esophagitis)

Definition of the Disease. Causes of the Condition
Esophageal erosion, also known as erosive esophagitis, is a chronic recurrent condition characterized by the formation of superficial defects on the mucous membrane due to excessive reflux of gastric contents, and sometimes duodenal contents.

Esophageal erosion represents the next stage of gastroesophageal reflux disease (GERD) when mucosal damage becomes more severe. Asymptomatic or minimally symptomatic GERD is particularly dangerous as patients may only become aware of the disease after defects develop in the esophagus and acute symptoms such as odynophagia—subjective painful sensations upon swallowing—develop. The prevalence of GERD varies from 8.1 to 31%, but the condition is actually more common as not all patients seek medical attention for it. Erosive esophagitis occurs in 37% of patients with GERD.

Causes of Esophageal Erosion
Factors that can contribute to the development of this pathology include:

  • Increased gastric acidity
  • Improper diet (eating late at night, overeating, lying down after meals, excessive consumption of coffee and carbonated drinks)
  • Increased intra-abdominal pressure caused by obesity, wearing tight belts and corsets, constipation, or other gastrointestinal disorders resulting in significant abdominal distension
  • Dysfunction of the lower esophageal sphincter (LES) due to increased intra-abdominal pressure, anatomical damage due to hiatus hernia, weakness of the diaphragm, and the use of medications that relax the LES
  • Harmful habits (smoking and alcohol consumption)
  • Use of certain medications (nonsteroidal anti-inflammatory drugs (NSAIDs), nitrates, calcium antagonists, antidepressants, progesterone, theophylline, doxycycline, and quinidine)

Symptoms of Esophageal Erosion

Primary symptoms of any esophageal erosion include:

  1. Heartburn – a burning sensation in the chest area. It occurs due to prolonged contact of gastric contents with the esophageal mucosa. It is the most common symptom, but its absence does not exclude the presence of esophageal erosions. Heartburn can be intermittent or persistent and worsens due to dietary errors, lying down after meals, or wearing tight belts or corsets.
  2. Belching – involuntary release of air or gases from the esophagus into the throat. It occurs quite often, especially after eating, overeating, consuming carbonated beverages, physical exertion, or lying down. Belching with esophageal erosion can vary:
  • Air belching occurs due to excessive swallowing of air during meals and may also accompany certain psychological disorders (e.g., anxiety and obsessive-compulsive disorders).
  • Acid belching occurs in diseases associated with increased gastric acidity, such as gastritis, H. pylori infection, etc.
  • Food belching occurs due to impaired motility of the upper gastrointestinal tract (GI).
  • Bitter belching occurs when duodenal contents are refluxed into the esophagus.
  • Putrid belching accompanies intestinal disorders, such as small intestinal bacterial overgrowth syndrome and GI motility disorders, where intestinal contents are regurgitated into the stomach and then into the esophagus.
  1. Odynophagia – the most characteristic symptom for esophageal erosions. It can manifest as mild discomfort or excruciating pain, significantly affecting the quality of life.
  2. Chest pain (cardiac syndrome) – resembles angina pain, mimics arrhythmia attacks and angina pain, radiating to the back, clavicle, neck, lower jaw, and left arm. However, unlike cardiac pain, it does not occur during physical exertion, so this symptom requires differential diagnosis and often complicates the establishment of the correct diagnosis.

Extraesophageal Manifestations of GERD and Erosive Esophagitis include:

  • Bronchopulmonary syndrome – may manifest as chronic cough and bouts of dyspnea.
  • Cardiac syndrome.
  • Otorhinolaryngological syndrome – throat pain, hoarseness.
  • Dental syndrome – dental caries, periodontitis, aphthous stomatitis.
  • Anemic syndrome – iron-deficiency anemia, including latent (hidden).

Classification and Stages of Esophageal Erosion

Several classifications are used to categorize erosive esophagitis. The most common is the Los Angeles classification, which includes 4 grades:

  • Grade A: One or more areas of mucosal damage less than 5 mm in size, with the area between the folds being normal; symptoms are usually absent. Erosions of this size are difficult to recognize and distinguish from normal mucosa, so this grade may sometimes be insufficient to diagnose erosive GERD.
  • Grade B: One or more areas of mucosal damage larger than 5 mm, but they also do not involve the area between the folds; may indicate the presence of erosive GERD if symptoms appear or proton pump inhibitor therapy shows a positive result.
  • Grade C: The damaged area extends across the mucosa between two or more folds but involves less than 75% of the esophageal circumference.
  • Grade D: More than 75% of the esophageal circumference is damaged. Together with Grade C, it unequivocally indicates the presence of erosive GERD.

Less common is the Savary-Miller classification:

  • Grade 0: No mucosal damage.
  • Grade I: Inflammation of the distal esophageal mucosa and/or individual erosions, occurring in 58.4% of cases.
  • Grade II: Coalescent erosions that do not involve the entire mucosal surface, occurring in 20.8% of cases.
  • Grade III: Large erosions circularly affecting the mucosa, occurring in 12.5% of cases.
  • Grade IV: Accompanied by complications such as chronic ulcer with formation of a perforation, esophageal stricture, and bleeding, occurring in 8.3% of cases.

In the International Classification of Diseases 10th revision (ICD-10), esophageal erosions are included in the “K21 Gastro-esophageal reflux disease, or GERD” group:

  • K21.0: Gastro-esophageal reflux with esophagitis.
  • K21.9: Gastro-esophageal reflux without esophagitis.

The Montreal classification of GERD is based on the clinical presentation and distinguishes between disease with esophageal and extra-esophageal manifestations. GERD can manifest differently: asymptomatically, with mild symptoms, with symptoms from only one group, or with mixed manifestations.

Diagnosis and classification depend on the type of symptoms and the degree of inflammation or visible erosion on the esophagus, leading to variations in treatment and clinical management of the disease.

Complications of Esophageal Erosion

The main and most dangerous complications include:

  • Bleeding from erosions: This is a dangerous and life-threatening complication, characterized by vomiting with blood and general symptoms of acute blood loss (weakness, paleness of the skin and mucous membranes, dry mouth, thirst, and increased heart rate).
  • Esophageal ulcer: The next stage of erosions, where there is a risk of bleeding and the formation of a perforation in the esophagus. In this case, the patient complains of retrosternal pain, odynophagia, heartburn, vomiting, and weight loss.
  • Esophageal stricture: This occurs with prolonged erosive esophagitis due to inadequate or absent treatment. Stricture prevents food from moving normally through the esophagus, leading to dysphagia – difficulty swallowing. The larger the affected area, the more severe the symptoms. In extensive processes, patients find it difficult not only to eat but also to drink. This complication requires costly endoscopic procedures, such as esophageal dilation, which is done in several stages. Often, such manipulations need to be repeated several times. In some cases, surgery is performed to remove the stricture.
  • Barrett’s esophagus (precancerous condition): One of the most dangerous complications of GERD, as it significantly increases the risk of developing esophageal adenocarcinoma. The danger lies in the fact that this condition can be asymptomatic or completely asymptomatic.

Diagnosis of esophageal erosion

StageQuestion0 Days1 Day2-3 Days4-7 Days
AHow often do you experience heartburn (burning sensation behind the breastbone)?0 points1 point2 points3 points
How often have you noticed stomach contents (fluids or food) come back into your throat or mouth (regurgitation)?0 points1 point2 points3 points
BHow often have you felt pain in the center of the upper abdomen?3 points2 points1 point0 points
How often have you felt nauseous?3 points2 points1 point0 points
CHow often has heartburn and/or regurgitation negatively affected your sleep?0 points1 point2 points3 points
How often have you taken medication without consulting a doctor during the past week due to heartburn and/or regurgitation?0 points1 point2 points3 points

The sensitivity of using the GerdQ questionnaire for diagnosing GERD (including erosive form) is 65%, and the specificity is 71%. The statistical probability of erosive esophagitis with scores between 8 and 10 is 48.5%, and between 11 and 18 is 60.7%.

Diagnostic Tools

Patients suspected of having erosive GERD are typically subjected to:

  1. Esophagogastroduodenoscopy (EGD): This procedure assesses the degree and extent of erosions, as well as the presence of complications.
  2. EGD with biopsy and morphological examination of the obtained material: This rules out Barrett’s esophagus, esophageal adenocarcinoma, and eosinophilic esophagitis. It is conducted not only when these disorders are suspected but also when treatment fails to yield results.
  3. Intraesophageal 24-hour pH monitoring or 24-hour pH-impedance monitoring: These studies detect refluxes, determine their quantity, duration, and the nature of the refluxate (i.e., whether only gastric contents or also duodenal contents reach the esophagus). They also assess the effectiveness of therapy and help determine the minimum effective dose of medications (including maintenance therapy). Such studies are prescribed for atypical forms of erosive esophagitis, which are accompanied by extraesophageal symptoms. They are also used if endoscopy shows no improvement and the patient is being prepared for surgery. pH monitoring is repeated after surgical intervention.
  4. Barium swallow X-ray: Initially, an abdominal X-ray is taken. Then the patient drinks barium sulfate, and the physician takes the primary targeted X-ray to determine the relief of the esophageal walls. The patient then drinks the remaining portion of the preparation (usually 250–300 ml, but sometimes more). X-rays are taken in different positions: lying on the back standardly or with the hips elevated at a 45° angle, lying on the side, and standing. The radiologist instructs the patient to hold their breath. X-rays are not only taken to refine the diagnosis but also to rule out hiatal hernia, esophageal stricture, and diffuse esophageal spasm. Bleeding is a contraindication to the study.

In cases of extraesophageal symptoms, consultation with related specialists is also required for differential diagnosis. Cardiologists, pulmonologists, otolaryngologists, and dentists assess the presence of angina, chronic bronchitis, pharyngitis, tonsillitis, otitis, bronchial asthma, pulmonary fibrosis, caries, aphthous stomatitis, and dental erosions.


Treatment for esophageal erosion aims to improve the patient’s quality of life, alleviate symptoms, heal the erosions, reduce inflammation in the esophageal lining, and prevent recurrence or complications. Typically, treatment includes both non-pharmacological and pharmacological methods. If conservative treatment proves ineffective, surgical intervention may be necessary.

Non-pharmacological treatment involves lifestyle changes such as:

  • Regulating diet: avoiding overeating, refraining from eating before bedtime, excluding fatty, spicy foods, coffee, tea, carbonated drinks, citrus fruits, chocolate, and other potential irritants to the esophagus.
  • Avoiding forward bending after meals and elevating the head of the bed at an angle of 15-20 cm.
  • Weight management.
  • Quitting smoking and reducing alcohol consumption.
  • Avoiding tight clothing and belts.

These lifestyle changes can significantly alleviate symptoms and aid in the healing of erosions.

Pharmacological treatment

Pharmacological treatment for erosive gastroesophageal reflux disease (GERD) primarily involves proton pump inhibitors (PPIs) such as Omeprazole, Esomeprazole, Lansoprazole, Dexlansoprazole, Pantoprazole, and Rabeprazole. PPIs have potent and long-lasting acid-suppressive effects, are generally well-tolerated, and rarely cause side effects. They can be used for extended periods without concerns of tolerance. A 2-month course of treatment is typically recommended for erosive GERD, regardless of the underlying cause. Depending on the severity, patients may require maintenance therapy, which involves longer-term or intermittent use of medications. The dosage and duration are determined by the physician based on the individual situation.

Patients may also be prescribed prokinetic agents, which tone the lower esophageal sphincter, normalize gastric emptying, enhance esophageal clearance, and help eliminate duodenogastric reflux. Common prokinetic drugs include Itopride hydrochloride, Trimbutin, Domperidone, Metoclopramide, Cisapride, and Tegaserod. However, the first four drugs are preferred due to their fewer side effects.

Esophagoprotectors aid in restoring the barrier function of the esophageal mucosa, thereby improving pre-epithelial protection. The main drug in this group is Alphazox.

Antacid medications quickly neutralize gastric acid but have a short duration of action, so they are typically used for symptom relief. Common antacid drugs include Maalox, Almagel, Phosphalugel, Rennie, Gaviscon, and Antareit.