Background

Erosive esophagitis is defined by inflammation and erosion of the esophageal lining, this is the tube that connects the stomach to the throat. The main cause of this condition is the esophagus’s repeated and extended exposure to stomach acid and digestive enzymes; this condition is frequently brought on by gastroesophageal reflux disease (GERD). Erosive esophagitis can cause a range of uncomfortable and sometimes painful symptoms, such as heartburn, difficulty swallowing, and chest pain. If left untreated, it might result in more serious side effects, such as bleeding and esophageal ulcers. 

Epidemiology

Prevalence: Roughly 30% of GERD cases result in the development of EE, and 1-13% of erosive esophagitis cases progress to the development of BE. 

Age and Gender: Although it can affect people of all ages, adults are more likely to experience erosive esophagitis, particularly those over the age of 40. It can affect both men and women, but there may be a slightly higher prevalence in men. 

Risk Factors:  

Gastroesophageal reflux disease (GERD): Chronic acid reflux is a major contributor to erosive esophagitis. 

Obesity: Excess body weight, especially around the abdomen, increases the risk of GERD and erosive esophagitis. 

Hiatal hernia: People with hiatal hernias are at a higher risk of developing erosive esophagitis. 

Smoking: The lower esophageal sphincter may become weaker as a result of tobacco smoking, allowing acid to reflux back into the oesophagus. 

Alcohol consumption: Excessive alcohol consumption can relax the lower esophageal sphincter and exacerbate GERD. 

Certain medications: Some medications, like nonsteroidal anti-inflammatory drugs (NSAIDs), can increase the risk of erosive esophagitis. 

Geographic Variation: The prevalence of erosive esophagitis may vary by geographic region, with higher rates in some parts of the world. Factors such as diet, lifestyle, and genetics can contribute to these variations. 

Anatomy

Pathophysiology

Gastroesophageal Reflux Disease (GERD): Erosive esophagitis often develops as a complication of GERD, It is distinguished by the stomach’s contents flowing into the oesophagus backward. This can happen due to a weakened lower esophageal sphincter (LES), which normally acts as a valve to prevent the contents of the stomach from flowing back into the esophagus. 

Chronic Acid Exposure: In individuals with GERD, the LES may not function properly, allowing gastric acid, bile, and partially digested food to reflux into the esophagus. Recurrent episodes of acid exposure result from the esophageal mucosa’s inadequate resistance to the stomach’s acidic environment. 

Mucosal Damage: Prolonged exposure to stomach acid and digestive enzymes irritates and damages the delicate lining of the esophagus. This constant insult can lead to inflammation and injury of the esophageal mucosa. 

Inflammatory Response: As the esophageal lining becomes damaged, the body’s inflammatory response is triggered. Localised inflammation results from the recruitment of inflammatory mediators, such as immune cells and cytokines, to the affected area. 

Etiology

Gastroesophageal Reflux Disease (GERD): The most typical cause of erosive esophagitis is GERD. It happens when the ring of muscle that divides the oesophagus from the stomach, known as the lower esophageal sphincter (LES), weakens or relaxes too much. This makes it possible for stomach acid to reflux back into the oesophagus, irritating and harming the lining of the oesophagus. 

Diet and Lifestyle: Erosive esophagitis and GERD can be made worse by specific food and lifestyle choices. These factors include consuming spicy or acidic foods, large meals, lying down after eating, obesity, smoking, and alcohol consumption. 

Medications: Some medications like NSAIDs and certain blood pressure medications, can relax the LES or irritate the esophageal lining, increasing the risk of erosive esophagitis. 

Smoking: Smoking can weaken the LES and impair the protective mechanisms of the esophagus, making it more susceptible to damage from gastric acid. 

Genetics

Prognostic Factors

Severity of Esophageal Injury: The degree and type of erosions and esophageal lining damage are critical factors in determining the prognosis. More extensive erosions are associated with a poorer prognosis. 

Chronicity: Long-term or chronic cases may be more challenging to manage and may have a less favourable outcome. 

Complications: The development of complications, such as barrett’s esophagus or esophageal structure, can worsen the prognosis. There is a link between barrett’s oesophagus and a higher risk of esophageal cancer. 

Age and General Health: A patient’s age and overall health can also impact the prognosis. Older individuals and those with other medical conditions may face additional challenges in managing erosive esophagitis. 

Clinical History

Erosive esophagitis can affect individuals of various age groups, but it is more commonly diagnosed in adults. The condition is often associated with gastroesophageal reflux disease (GERD), which tends to occur more frequently in adults. While it can occur at any age, it is less common in children and adolescents. The age group most affected by erosive esophagitis typically ranges from early adulthood to the elderly, with the risk increasing as individuals get older. 

Physical Examination

Endoscopy: This technique makes use of an endoscope, a flexible tube that has a light source attached to it and a camera at its tip, enabling a direct visualization of the esophagus. 

Barium X-rays: These X-ray images are captured in tandem with the ingestion of a barium solution. This unique contrast agent adheres to the esophageal lining, appearing as a bright white substance in X-ray imagery, thereby enhancing the clarity of the esophageal visualization. 

Biopsy: This procedure typically requires an invasive approach, often performed in the context of endoscopy, to allow for the examination of inflamed tissue under a microscope 

A culture: A specimen from a potentially contaminated region is collected to determine the specific microorganisms responsible for an infection. 

Age group

Associated comorbidity

Gastroesophageal Reflux Disease (GERD): Erosive esophagitis is commonly associated with GERD, a condition where stomach acid frequently flows back into the esophagus. GERD is a major risk factor for erosive esophagitis. 

Hiatal Hernia: Hiatal hernias can contribute to the development of erosive esophagitis.  

Obesity: Excess body weight and obesity are known risk factors for both GERD and erosive esophagitis. The increased pressure on the stomach can lead to more frequent reflux episodes. 

Smoking: The muscle ring that keeps the oesophagus and stomach apart can become weaker because of smoking. This weakening can result in increased acid reflux and contribute to erosive esophagitis. 

Alcohol Consumption: Excessive alcohol consumption can relax the lower esophageal sphincter, leading to more frequent acid reflux episodes. 

Certain Foods: Spicy, acidic, and fatty foods can exacerbate erosive esophagitis symptoms. Avoiding trigger foods is often recommended to manage the condition. 

Stress: Chronic stress and anxiety may lead to behaviors that exacerbate erosive esophagitis, such as overeating or consuming trigger foods. 

Age: Erosive esophagitis is more common in older individuals, possibly due to weakened esophageal muscles and other age-related factors. 

Family History: There may be a genetic component to the development of erosive esophagitis, as it tends to run in families. 

Associated activity

Acuity of presentation

Mild to Moderate Acuity: Many people with erosive esophagitis experience symptoms that are relatively mild or moderate in intensity. These symptoms may include: 

Heartburn (acid reflux): A burning feeling in the chest or throat that often occurs when reclining or immediately following a meal. 

Regurgitation: The backflow of stomach contents or acid into the mouth or throat. 

Difficulty swallowing: Known as dysphagia, it may feel like food is getting stuck in the throat. 

Severe Acuity: In some cases, erosive esophagitis can lead to more severe symptoms and complications. These may include: 

Bleeding: Erosion of the esophageal lining can result in bleeding, which may manifest as dark, tarry stools or vomiting blood. 

Strictures: Repeated damage to the esophagus can cause narrowing (strictures) that make swallowing extremely difficult. 

Respiratory Symptoms: Aspiration of stomach acid into the lungs can lead to cough, wheezing, or other respiratory issues.

Differential Diagnoses

Gastroesophageal Reflux Disease (GERD): GERD is one of the most common causes of erosive esophagitis. Stomach acid commonly refluxes into the oesophagus in this chronic illness, irritating and eroding the lining of the oesophagus. 

Peptic Ulcer Disease: Peptic ulcers can develop in the stomach or the duodenum, and their symptoms, including epigastric pain and acid reflux, may overlap with erosive esophagitis. 

Infectious Esophagitis: Various infections, such as candidiasis (caused by Candida yeast), herpes esophagitis (caused by the herpes simplex virus), or cytomegalovirus (CMV) esophagitis, can lead to symptoms resembling erosive esophagitis. 

Barrett’s Esophagus: Barrett’s oesophagus is a disorder where columnar epithelium replaces the typical squamous epithelium lining the oesophagus. It can raise the risk of esophageal cancer and is frequently brought on by persistent GERD. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Lifestyle Modifications:  

Dietary Changes: 

Avoid trigger foods and beverages that can worsen symptoms, such as citrus fruits, tomatoes, spicy foods, caffeine, alcohol, and fatty or fried foods. 

Consume smaller, more frequent meals to reduce pressure on the lower esophageal sphincter (LES). 

Smoking Cessation: 

Quitting smoking can improve LES function and reduce esophageal irritation. 

Medications 

Antacids: 

Over-the-counter antacids, such as Tums or Maalox, can provide quick relief by neutralizing stomach acid. 

H2 Blockers (Histamine-2 Receptor Antagonists): 

Medications like ranitidine (Zantac) and famotidine (Pepcid) reduce the production of stomach acid. 

Proton Pump Inhibitors (PPIs): 

These are potent acid-suppressing medications, such as omeprazole (Prilosec) or esomeprazole (Nexium), that help heal the esophagus by reducing acid production. 

Prokinetics: 

These medications help improve esophageal motility and prevent reflux. Examples include metoclopramide (Reglan). 

Alginate Medications: 

Medications containing alginic acid create a protective barrier in the stomach, reducing reflux symptoms. 

Mucosal Protectants: 

Sucralfate (Carafate) may be prescribed to coat and protect the esophageal lining. 

Endoscopic Therapy: 

In severe cases or when medications are not effective, endoscopic procedures like fundoplication or radiofrequency ablation (Stretta procedure) can be considered to tighten the LES and prevent reflux. 

Surgical Intervention: 

Nissen fundoplication and other surgical procedures could be advised in rare circumstances where non-surgical therapy are ineffective. To stop reflux, this operation entails encircling the lower oesophagus with the upper portion of the stomach. 

Monitoring and Follow-up: 

Regular follow-up with a healthcare provider is crucial to assess the effectiveness of treatment, manage any side effects of medications, and monitor for complications like Barrett’s esophagus or strictures. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

lifestyle-modifications-in-treating-erosive-esophagitis

Dietary Modifications:  

Avoid trigger foods: Identify and eliminate or reduce intake of foods and beverages that can trigger acid reflux, such as spicy, acidic, and fatty foods, caffeine, alcohol, and carbonated drinks.  

Smaller, more frequent meals: Smaller, more frequent meals are preferable to three larger ones in order to ease the strain on the lower esophageal sphincter (LES) and avoid severe acid reflux. 

Maintain a healthy weight: Excess body weight can increase abdominal pressure, pushing stomach contents into the esophagus. Managing your weight through a balanced diet can help reduce symptoms. 

Elevate Your Sleeping Position: When you go to sleep, raise the head of your bed by six to eight inches to stop stomach acid from running down your throat. As an alternative, you can get a comparable result by using a wedge pillow. 

Avoid Lying Down After Eating: To lessen the chance of acid reflux and give your stomach time to empty, after eating, wait for at least two to three hours before lying down or going to bed. 

Smoking Cessation: If you smoke, consider quitting, as smoking can relax the LES and contribute to acid reflux. 

Manage Stress: Stress can exacerbate symptoms of erosive esophagitis. Incorporate stress-reduction techniques such as meditation, yoga, deep breathing exercises, and regular physical activity into your routine. 

Medication: Consult your healthcare provider for appropriate medications to control stomach acid production and reduce inflammation in the esophagus. Proton pump inhibitors (PPIs), H2 blockers, and antacids are common medications used. 

Avoid Tight Clothing: Wearing tight belts or clothing that constricts your abdomen can increase abdominal pressure and promote acid reflux. Opt for looser-fitting attire. 

Keep a Food Diary: Keep track of your diet and note which foods trigger symptoms. This can help you identify and avoid specific triggers. 

Effectiveness of proton pump inhibitors in treating erosive esophagitis

omeprazole 

omeprazole works by inhibiting the action of proton pumps in the stomach. Proton pumps are responsible for producing stomach acid. By blocking these pumps, Omeprazole significantly reduces the production of acid in the stomach. Omeprazole can provide relief from the symptoms associated with erosive esophagitis, such as heartburn, regurgitation, chest pain, and difficulty swallowing. 

omeprazole serves as a convenient initial choice for managing EE due to its accessibility as an over-the-counter (OTC) generic medication, and its inclusion in most formularies. A substantial portion of EE patients may necessitate a daily 40 mg dosage, which exceeds the FDA-approved amount for GERD. This dosage aligns with the latest guidelines. 

esomeprazole  

esomeprazole works by reducing the production of stomach acid. It does this by inhibiting the proton pump (the H+/K+ ATPase enzyme) in the stomach’s lining. By decreasing acid production, it helps to heal and prevent further damage to the esophagus. 

pantoprazole  

pantoprazole works by inhibiting the proton pump in the cells of the stomach lining. This reduces the production of gastric acid, helping to alleviate the symptoms associated with erosive esophagitis, such as heartburn and regurgitation. 

Role of H2 blockers in treating erosive esophagitis

cimetidine  

cimetidine functions by preventing histamine from binding to stomach H2 receptors, which in turn reduces the secretion of stomach acid. By decreasing the amount of acid in the stomach, it can help reduce the acidity of the gastric contents that reflux into the esophagus, thereby decreasing the irritation and damage to the esophageal lining. By reducing acid production, cimetidine can alleviate the symptoms of erosive esophagitis, such as heartburn, chest pain, and difficulty swallowing. Additionally, it can help injured esophageal tissue repair. 

famotidine  

famotidine functions as a competitive antagonist of histamine H-receptors (H2RA). It interacts with H-receptors situated on the basolateral membrane of parietal cells in the stomach, ultimately preventing the effects of histamine.

Its pharmacological properties lead to the reduction of gastric secretion by diminishing both the acidity and quantity of gastric fluid produced. It is used to alleviate the symptoms associated with erosive esophagitis. 

role-of-endoscopic-procedures-in-treating-erosive-esophagitis

Endoscopy: In some cases, an endoscopy may be performed to evaluate the extent of esophageal damage and to take biopsies for further evaluation. 

Fundoplication: In severe cases or when medical management fails, fundoplication surgery may be considered. This procedure wraps the top of the stomach around the LES to strengthen it and prevent reflux. 

management-of-erosive-esophagitis

Diagnosis and Evaluation: 

Initial diagnosis: A healthcare provider typically diagnoses erosive esophagitis based on the patient’s symptoms, medical history, and physical examination. 

Diagnostic tests: To validate the diagnosis and assess the severity of the issue, several diagnostic tests could be performed, including endoscopy, esophageal pH monitoring, and barium swallow studies. 

Lifestyle Modifications: 

Dietary changes: Patients are often advised to make specific dietary modifications, such as avoiding trigger foods like spicy, acidic, and fatty foods, as well as caffeine, alcohol, and chocolate. 

Weight management: Retaining a healthy weight can ease the lower esophageal sphincter’s burden, which can improve symptoms. 

Meal timing: Eating smaller, more frequent meals and avoiding late-night or large meals can help reduce reflux. 

Medication Management: 

Proton pump inhibitors (PPIs): These medications are commonly prescribed to reduce stomach acid production, which helps heal esophageal erosion and relieve symptoms. 

H2 blockers: Histamine-2 receptor antagonists can also reduce stomach acid production and provide relief from symptoms. 

Antacids: Over-the-counter antacids can provide short-term relief by neutralizing stomach acid. 

Healing and Symptom Control: 

After initiating medical treatment, patients are monitored for symptom improvement and healing of esophageal erosions, which may be assessed through follow-up endoscopy or other diagnostic tests. 

Medication adjustments: Dosages of medications may need to be adjusted based on the individual patient’s response to treatment. 

Long-term management: In some cases, patients may require ongoing or intermittent use of medication to control symptoms and prevent erosive esophagitis from recurring. 

Monitoring and Maintenance: 

Regular follow-up: Patients with erosive esophagitis may need periodic check-ups and endoscopic evaluations to monitor the condition and make treatment adjustments as necessary. 

Lifestyle adherence: Encouraging patients to maintain lifestyle modifications and dietary restrictions is crucial for long-term symptom control and prevention. 

Reflux management education: Patients should be educated about the importance of avoiding known triggers and managing their condition effectively. 

Surgical Intervention (if necessary): 

In cases of severe erosive esophagitis or when conservative treatments are ineffective, surgical options, such as fundoplication, may be considered to prevent reflux. 

Complication Management: 

Addressing complications: If complications such as esophageal strictures or Barrett’s esophagus develop, additional treatment or surveillance may be required. 

Medication

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References

Erosive esophagitis and nonerosive reflux disease (NERD): comparison of epidemiologic, physiologic, and therapeutic characteristics – PubMed (nih.gov)