Reflux Esophagitis: Understanding Your Pathology Report

by Jason Wasserman MD PhD FRCPC
July 29, 2026

Reflux esophagitis is inflammation and injury of the lining of the esophagus, the muscular tube that carries food and liquid from the mouth to the stomach, caused by stomach contents flowing backward into it. The esophagus is lined by squamous cells, which are built to withstand the friction of swallowing but not the acid and digestive enzymes of the stomach. Repeated exposure damages that lining and triggers an inflammatory response.

Reflux esophagitis and gastroesophageal reflux disease (GERD) are related but are not the same thing, and the difference matters when reading your report. GERD is the clinical condition of having troublesome symptoms or complications from reflux. Reflux esophagitis is the visible injury to the esophageal lining that reflux can cause. Fewer than half of people with typical GERD symptoms have any visible damage on endoscopy; the rest have what is called non-erosive reflux disease. Conversely, some people have esophagitis with few or no symptoms. A diagnosis of reflux esophagitis therefore tells you that the lining has actually been injured, which is more specific information than a diagnosis of GERD alone.

Reflux esophagitis is common and, in most people, is well controlled with treatment. This article will help you understand the findings in your pathology report, what each term means, and why it matters for your care.

What causes reflux esophagitis?

Reflux esophagitis is caused by stomach contents, mainly acid but also bile and digestive enzymes, flowing backward into the esophagus. A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter, normally stays closed to prevent this. When it relaxes at the wrong times, or when pressure inside the abdomen overwhelms it, reflux occurs and the lining is exposed to material it is not built to handle.

Factors that make this more likely include:

Hiatal hernia — Part of the stomach slides upward through the opening in the diaphragm, which weakens the barrier at the bottom of the esophagus. This is the most important anatomic cause and is strongly associated with more severe esophagitis.
Obesity, particularly around the abdomen — Increases pressure that pushes stomach contents upward.
Pregnancy — Both from pressure of the growing uterus and from hormonal effects on the sphincter.
Smoking — Reduces sphincter pressure and saliva production, both of which normally protect the lining.
Delayed stomach emptying — When the stomach empties slowly, as can occur in long-standing diabetes, contents remain available to reflux for longer.
Certain medications — Including calcium channel blockers and nitrates for blood pressure, some asthma medications, sedatives, and drugs with anticholinergic effects, all of which can relax the sphincter.
Connective tissue disease — Systemic sclerosis (scleroderma) in particular weakens the muscle of the esophagus and the sphincter, and often causes severe reflux.
Meal patterns and body position — Large meals, eating shortly before lying down, and bending over after eating all increase reflux episodes.

Foods such as coffee, chocolate, alcohol, citrus, and fatty or spicy meals are often described as triggers. The evidence that any of these causes esophagitis is weak, and current guidance has moved away from asking everyone to avoid a standard list, toward identifying the specific foods that reliably provoke symptoms for a given person. Alcohol is the exception worth singling out, since it both relaxes the sphincter and irritates the lining directly.

What are the symptoms of reflux esophagitis?

The symptoms of reflux esophagitis come from acid contacting the injured lining of the esophagus. The most common is heartburn, a burning sensation behind the breastbone that often rises toward the throat. Regurgitation, in which sour or bitter fluid comes back up into the throat or mouth, is the other classic symptom.

Other symptoms include chest pain, pain on swallowing, a sensation of food sticking, chronic cough, hoarseness, sore throat, and disturbed sleep. Symptoms are typically worse after large meals, when lying flat, and when bending forward.

Two points are worth knowing. First, symptoms correlate poorly with how much damage is present: some people with severe esophagitis have few symptoms, and some people with intense heartburn have a normal-looking esophagus. Second, progressive difficulty swallowing solid foods, unexplained weight loss, vomiting, or evidence of bleeding are not typical of uncomplicated reflux esophagitis and warrant prompt assessment, since they can indicate a narrowing, an ulcer, or something more serious.

How is the diagnosis made?

Reflux esophagitis is suspected from symptoms and confirmed by looking directly at the lining of the esophagus during an upper endoscopy, in which a thin flexible tube with a camera is passed through the mouth. Injured areas appear as breaks in the lining, described as erosions, in the lower esophagus just above the stomach.

When erosions are present, the endoscopist grades their extent using the Los Angeles classification, which appears on the endoscopy report:

Grade A — One or more breaks in the lining, each no longer than 5 mm.
Grade B — At least one break longer than 5 mm, but breaks do not run together between the tops of two folds of the lining.
Grade C — Breaks run together between the tops of two or more folds, involving less than three-quarters of the circumference of the esophagus.
Grade D — Breaks involve three-quarters or more of the circumference.

Grades A and B are considered mild and are much more common than grades C and D. The grade guides how long acid-suppressing treatment is given and whether a repeat endoscopy is needed afterward. Grade B or higher is regarded as conclusive evidence of reflux disease, while grade A alone is less definitive because small breaks can be seen in people without reflux disease.

Biopsies, small tissue samples, may be taken and sent to a pathologist for examination under a microscope. Biopsies are not needed to diagnose reflux esophagitis, which is an endoscopic diagnosis. They are taken for a different purpose: to look for the other conditions that can inflame the esophagus and look similar, and to check for Barrett esophagus.

This leads to an important limitation. The microscopic changes of reflux esophagitis are real but not unique to reflux; the same features appear in several other conditions. For this reason a pathology report will often say the findings are “consistent with” or “compatible with” reflux esophagitis rather than stating it definitively. That wording is not hedging or uncertainty about your care. It reflects the fact that the microscope shows injury and inflammation, while the cause is established by combining that with your symptoms and what the endoscopist saw.

Microscopic findings

When a biopsy from the esophagus is examined in reflux esophagitis, the pathologist describes a set of specific changes in the squamous lining. Any or all of these may be listed on your report:

Basal cell hyperplasia — The basal cells at the bottom of the lining multiply and form a thicker layer than normal. This is the lining trying to replace cells that are being lost from the surface, and it is one of the two most characteristic findings.
Elongated papillae — The papillae, finger-like projections of the tissue beneath the lining, extend further up toward the surface than they should. This is the other characteristic finding and accompanies basal cell hyperplasia.
Dilated intercellular spaces (spongiosis) — Small gaps open between the squamous cells as fluid seeps between them. This is one of the earliest changes and can be present before anything is visible on endoscopy.
Intraepithelial inflammatory cells — Immune cells move into the lining. Eosinophils are the most characteristic type in reflux and are discussed in the next section. Neutrophils, which signal acute inflammation, appear mainly in more severe or eroded cases rather than in mild reflux. Lymphocytes and plasma cells may also be increased.
Vascular congestion — Blood vessels in the tissue just beneath the lining become dilated and prominent.
Erosion — Part of the thickness of the lining has been worn away. When erosions are described, the report may use the term erosive esophagitis.
Ulcer — The full thickness of the lining has been lost, exposing the tissue beneath. This indicates more severe injury.

A biopsy showing only mild changes does not mean your symptoms are not real, and a biopsy that looks close to normal is common in people with genuine reflux disease. The pathologist also checks whether the lining has begun to be replaced by gland-forming cells, which would indicate Barrett esophagus.

Eosinophils and the difference from eosinophilic esophagitis

If your report from a biopsy for reflux esophagitis mentions eosinophils, this section explains what that means. Eosinophils are immune cells associated with allergic reactions and tissue irritation. They are not normally present in the lining of the esophagus at all, so any number is abnormal. Both reflux esophagitis and a separate condition called eosinophilic esophagitis produce eosinophils in the lining, and telling the two apart matters a great deal because they are treated in completely different ways.

The main tool for separating them is the number of eosinophils the pathologist counts in a single high-power microscope field:

Fewer than 15 eosinophils per high-power field — Typical of reflux esophagitis, where the count is usually low, often just a few scattered cells, and concentrated in the lower esophagus.
15 or more eosinophils per high-power field — The threshold used to diagnose eosinophilic esophagitis, particularly when the count is high in the upper and middle esophagus as well as the lower, and when the endoscopy shows features such as rings, furrows, or white patches.

The count alone does not settle the question. Distribution matters, since reflux involves the lower esophagus while eosinophilic esophagitis usually affects the whole length, which is why biopsies are taken from several levels when this condition is suspected. Endoscopic appearance and symptoms matter too. A report noting increased eosinophils without reaching the threshold is a common and expected finding in reflux esophagitis and does not mean you have an allergic condition.

Other causes of esophagitis

Reflux is the most common cause of esophagitis but not the only one, and part of the reason biopsies are taken is to identify or exclude the others. Your report may mention that these have been considered:

Infection — Candida, a yeast, is the most common and is identified with a special stain. Herpes simplex virus and cytomegalovirus can also cause esophagitis, usually in people whose immune system is weakened.
Pill esophagitis — A tablet or capsule lodges in the esophagus and injures the lining directly. Common culprits include certain antibiotics, potassium tablets, iron supplements, and bisphosphonates for osteoporosis.
Eosinophilic esophagitis — An immune and allergy-driven condition, described in the section above.
Lymphocytic esophagitis — An uncommon pattern in which intraepithelial lymphocytosis predominates, sometimes associated with other conditions.
Caustic or radiation injury — After swallowing a corrosive substance or after radiation therapy to the chest.

What are the possible complications of reflux esophagitis?

Most people with reflux esophagitis do well with treatment and never develop complications. When reflux continues untreated over many years, the repeated cycle of injury and repair can lead to:

Peptic stricture — Scar tissue from repeated healing narrows the esophagus, causing progressive difficulty swallowing solid foods. This can usually be treated by stretching the narrowed area during an endoscopy.
Ulcer and bleeding — Deep ulcers can bleed, sometimes slowly enough to cause anemia without any visible blood.
Barrett esophagus — The squamous lining is replaced by gland-forming cells resembling those of the intestine, a change called intestinal metaplasia. This occurs in a minority of people with long-standing reflux and is important because it is the precursor to adenocarcinoma of the esophagus.

Barrett esophagus is the complication people most often worry about, so it is worth putting in proportion. It develops in only a minority of those with chronic reflux, and among people who do have Barrett esophagus, roughly 0.3% per year go on to develop cancer. Most never do. Reflux esophagitis itself does not become cancer; the risk runs specifically through Barrett esophagus, which is why a one-time screening endoscopy is discussed for people with long-standing reflux plus several other risk factors such as male sex, age over 50, obesity, smoking, and a family history.

What happens after this diagnosis?

Treatment of reflux esophagitis aims to reduce acid exposure so the lining can heal, and then to keep it healed. Acid-suppressing medication is the mainstay. A proton pump inhibitor taken once daily before a meal heals most cases, typically over four to eight weeks, with the longer course used for more extensive esophagitis. Medications called H2 receptor blockers are less potent but may be used for milder disease or added at night. After healing, some people can stop treatment or step down to the lowest effective dose, while those with more severe esophagitis usually continue long-term, since it tends to recur when treatment stops.

Measures discussed alongside medication include losing weight where relevant, stopping smoking, avoiding meals within about three hours of lying down, raising the head of the bed, and identifying and limiting the specific foods that provoke symptoms for you. These help most in people who can identify a clear pattern.

A repeat endoscopy after treatment is generally recommended for more extensive esophagitis (Los Angeles grades C and D), both to confirm healing and because Barrett esophagus underneath an inflamed lining can only be reliably identified once the inflammation has settled. Mild esophagitis that responds to treatment usually needs no repeat examination.

For people whose symptoms persist despite adequate acid suppression, further testing may be considered, including pH monitoring to measure how much acid actually reaches the esophagus and manometry to assess how well the esophageal muscle works. Anti-reflux surgery or endoscopic procedures to reinforce the barrier at the bottom of the esophagus are options for a small number of people with well-documented reflux who do not respond to or do not wish to continue medication.

Questions to ask your doctor

Did my biopsy show any evidence of Barrett esophagus?
Were eosinophils seen in my biopsy, and if so, how many?
Has eosinophilic esophagitis been ruled out, and were biopsies taken from more than one level of my esophagus?
Were any other causes of esophagitis, such as infection or a medication, considered?
Did my report mention an ulcer, and if so, does that change my treatment?
Which medication should I take, at what dose, and for how long?
Should I have a repeat endoscopy to confirm healing?
Will I need to stay on acid-suppressing medication long term, and what are the risks of doing so?
Do I have a hiatal hernia, and does it affect my treatment?
Based on my risk factors, should I be screened for Barrett esophagus?
Which lifestyle changes are most likely to help in my case?
What symptoms should prompt me to contact you before my next appointment?