Erosive esophagitis means that the lining of the esophagus, the muscular tube that carries food and liquid from the mouth to the stomach, is inflamed and has been worn away in places. The esophagus is lined by squamous cells, which form a protective surface layer called the epithelium. When injury damages this layer faster than it can be replaced, part of it breaks down and an erosion is created.
An important point first: erosive esophagitis is a description of what was seen, not a disease in itself. It tells you how much damage is present, but it does not say what caused it. Several different conditions produce erosions in the esophagus, and they are treated in very different ways. Establishing the cause is the main task that follows this finding, and it is usually the reason biopsies were taken.
Your report may also distinguish between two depths of damage. An erosion is a loss of part of the thickness of the lining. An ulcer is a loss of the full thickness, exposing the tissue beneath. Ulcers indicate deeper injury and are more likely to bleed or to leave scarring as they heal. This article will help you understand the findings in your pathology report, what each term means, and why it matters for your care.
Erosive esophagitis is caused by anything that injures the lining of the esophagus faster than it can repair itself. The possible causes differ enough in treatment that identifying the right one matters:
One further reason biopsies are taken from an eroded or ulcerated area deserves mention. A cancer of the esophagus that has broken down at its surface can look much like inflammatory ulceration on endoscopy. Sampling the area is a routine precaution that allows this to be excluded, and in the great majority of cases it is excluded. Ulcers that do not heal after adequate treatment are usually biopsied again for the same reason.
The symptoms of erosive esophagitis come from acid, food, and liquid contacting exposed tissue where the protective lining has been lost. The most characteristic is odynophagia, meaning pain on swallowing, which is more suggestive of erosive damage than heartburn alone. Heartburn, chest discomfort, difficulty swallowing, and a sensation of food sticking are also common.
Symptoms correlate poorly with the amount of damage. Some people with extensive erosions have few complaints, particularly older adults and people with long-standing diabetes, while others with minor damage are very uncomfortable. Vomiting blood, passing black stools, or developing unexplained anemia can indicate bleeding from an erosion or ulcer and warrant prompt assessment, as does progressive difficulty swallowing solid foods or unexplained weight loss.
Erosive esophagitis is identified during an upper endoscopy, in which a thin flexible tube with a camera is passed through the mouth to examine the lining of the esophagus directly. This is an endoscopic finding rather than a microscopic one: the endoscopist sees breaks in the lining, which appear as red, raw-looking streaks or patches, sometimes with a white or yellow coating of inflammatory debris. The lining around them may look red and swollen.
Where the erosions are located gives the first clue to the cause. Damage concentrated in the lower esophagus points toward reflux, damage in the middle of the esophagus toward a pill, discrete punched-out ulcers toward a viral infection, and white plaques toward Candida. Erosions along the whole length raise other possibilities.
During the endoscopy, small tissue samples called biopsies are usually taken and sent to a pathologist for examination under a microscope. The purpose of the biopsy is not to confirm that erosions are present, since the endoscopist has already seen them. It is to look for the specific features that point to one cause over another, to check for Barrett esophagus, and to exclude cancer. For this reason, a pathology report will often describe the injury and then say the findings are “consistent with” a particular cause rather than stating it definitively, because the final answer combines the microscope with the endoscopic appearance and your symptoms.
When erosive esophagitis is caused by reflux, the endoscopist grades how extensive the damage is using the Los Angeles classification. This grade appears on the endoscopy report and guides how long treatment is given:
Grades A and B are considered mild and account for the large majority of cases, commonly around 80% or more. Grades C and D are uncommon and indicate more severe disease that needs a longer course of treatment and a repeat endoscopy afterward. Grade B or higher is regarded as conclusive evidence that reflux is the cause; grade A alone is less definitive, because small breaks are occasionally seen in people who do not have reflux disease.
When a biopsy taken from an area of erosive esophagitis is examined under the microscope, the pathologist describes both the damage itself and any clues to its cause. Findings that may appear on your report include:
Certain additional findings point toward a specific cause:
Most erosive esophagitis heals completely once the cause is treated. Complications arise mainly when the injury is severe, or when the cause is not identified and the damage continues:
The cancer risk is worth putting in proportion. Erosive esophagitis does not itself turn into cancer. The risk runs specifically through Barrett esophagus, which develops in only a minority of people with long-standing reflux, and among those who have it, roughly 0.3% per year go on to develop cancer. Most never do.
What follows depends on the cause. Because the erosions themselves heal once the injury stops, treatment is directed at whatever produced them.
When reflux is the cause, a proton pump inhibitor taken once daily before a meal is the mainstay. Mild disease usually heals over about four weeks and more extensive disease over eight, with higher or twice-daily dosing used for grades C and D. Measures discussed alongside medication include weight loss where relevant, stopping smoking, avoiding meals within about three hours of lying down, raising the head of the bed, and reducing alcohol. Many people with severe erosive esophagitis stay on long-term treatment, since it tends to recur when medication is stopped.
When another cause is identified, treatment follows it: antifungal medication for Candida, antiviral medication for herpes or cytomegalovirus, stopping or changing the responsible drug and taking future tablets upright with plenty of water for pill esophagitis, and dietary or anti-inflammatory treatment for eosinophilic esophagitis.
A repeat endoscopy after treatment is generally recommended for Los Angeles grades C and D. This confirms healing, and it allows Barrett esophagus to be assessed properly, since it cannot be reliably identified underneath actively inflamed lining. A repeat examination is also usual when an ulcer was present, to confirm it has closed. Mild erosive esophagitis that responds well to treatment does not normally need a follow-up endoscopy.
Where symptoms persist despite adequate treatment, further testing may be considered, including pH monitoring to measure how much acid actually reaches the esophagus and manometry to assess the muscle function of the esophagus.