Erosive Esophagitis; Causes, Symptoms, Diagnosis, Treatment

Erosive esophagitis is defined as inflammation of the esophagus, which is the tube that connects the throat to the stomach.Esophagitis can be caused by infection, irritation of the esophagus, or inflammation of the lining of the esophagus.The esophagus is part of the digestive system, specifically the gastroinetestinal tract. It is a muscular tube where food passes through from the mouth to the stomach. Esophagitis is a disease that can be painful and can make swallowing difficult. However, esophagitis can be asymptomatic. Esophagitis can be caused by infection, irritation, and/or inflammation of the lining of the esophagus.

Types of Erosive Esophagitis

There are several types of esophagitis.

Reflux esophagitis – is caused by a reflux of stomach acid into the esophagus. This can lead to erosive esophagitis.
Eosinophilic esophagitis – This esophagitis is caused by a high concentration of eosinophils in the esophagus. The presence of eosinophils in the esophagus may be due to an allergen, and is often correlated with GERD. The direction of cause and effect between inflammation and acid reflux is poorly established, with recent studies (in 2016) hinting that reflux does not cause inflammation. This esophagitis can be triggered by allergies to food or to inhaled allergens. This type is still poorly understood.
Drug-induced esophagitis – Damage to the esophagus due to medications. If the esophagus is not coated or if the medicine is not taken with enough liquid, it can damage the tissues.
Lymphocytic esophagitis – Lymphocytic esophagitis is when there is an increased amount of lymphocytes in the lining of the esophagus. It is a rare condition. It could be connected to eosinophilic esophagitis.
Caustic esophagitis – Caustic esophagitis is the damage of tissue via chemical origin, this occurred while teenagers intentionally ate tide pods.
Infectious esophagitis – is caused by bacteria, viruses, or fungus.
Barrett’s esophagus – results from untreated inflammation of the esophagus that can cause changes in the type of cells that make up the inner lining (mucosa) of the esophagus. Barrett’s esophagus increases the risk for esophageal cancer.
Behçet’s syndrome (also called Behçet’s disease) – is a form of vasculitis that can cause ulcers in the mouth, esophagus and other parts of the body. This disease is rare in the U.S.
Graft-versus-host disease – is a complication that can occur after a transplant (usually bone marrow transplant) when the newly transplanted cells attack the recipient’s body. Esophagitis may occur in this condition.
Cancer esophagitis – may be a symptom of cancer of the esophagus, or metastatic cancer (cancer that started in another part of the body and then spreads to the esophagus).

Causes of Erosive Esophagitis

Cause esophagitis include

Candida – This is a yeast infection of the esophagus caused by the same fungus that causes vaginal yeast infections. The infection develops in the esophagus when the body’s immune system is weak, such as in people with diabetes or HIV. It is usually very treatable with antifungal drugs.
Herpes – Like Candida, this viral infection can develop in the esophagus when the body’s immune system is weak. It is treatable with antiviral drugs.

Medicines – Can cause esophageal damage that can lead to esophageal ulcers

Nonsteroidal anti-inflammatory drugs (NSAIDS) – aspirin, naproxen sodium, and ibuprofen. Known to irritate the GI tract.
Antibiotics – doxycycline and tetracycline
Quinidine
Bisphosphonates – used to treat osteoporosis
Steroids
Potassium chloride

Others causes of Erosive Esophagitis

Chemical injury by alkaline or acid solutions
Physical injury resulting from nasogastric tubes.
Alcohol abuse – Can wear down the lining of the esophagus.
Crohn’s disease – a type of IBD and an autoimmune disease that can cause esophagitis if it attacks the esophagus.
Stress – Can cause higher levels of acid reflux
Radiation therapy-Can affect the immune system.
Allergies (food, inhalants)– Allergies can stimulate eosinophilic esophagitis.
Infection-People with an immunodeficiencies have a higher chance of developing esophagitis.
Vitamins and supplements (iron, Vitamin C, and potassium)-Supplements and minerals can be hard on the GI tract.
Vomiting – Acid can irritate esophagus.
Hernias -A hernia can poke through the diaphragm muscle and can inhibit the stomach acid and food from draining quickly.
Surgery

Irritation leading to esophagitis may be caused by any of the following:

GERD, or gastroesophageal reflux disease
Vomiting
Surgery
Medications such as aspirin and other anti-inflammatory drugs
Taking a large pill with too little water or just before bedtime
Swallowing a toxic substance
Hernias
Radiation injury as can occur following radiation treatment for cancer

Symptoms of Erosive Esophagitis

The signs and symptoms for esophagitis include

Heartburn feels like the inside of your chest is burning. It is a symptom of acid reflux or GERD.
Swallowing is painful and difficult to pass food through your throat into your esophagus.
Vomiting, also known as emesis, is the release of the contents of the stomach through the mouth or nose.
Abdominal pain is when pain is felt in the abdomen.
Food bolus impaction is an obstruction of the esophagus by swallowed food.
Acid regurgitation is the backflow of acid from the stomach to the mouth.
Chest pain is pain felt between the neck and upper abdomen. There are many causes and the pain can range.
Cough is a reflex to clear the throat of irritants or mucus.
New or worsening asthma
Disrupted sleep
A burning sensation in your chest (heartburn), usually after eating, which might be worse at night
Tightness in your chest or upper abdomen. The pain may wake you up in the middle of the night.
Regurgitation, the backflow of stomach fluids into your mouth
Nausea
A recurring sour or bitter taste in the mouth
Difficulty swallowing
Sore throat
Coughing, wheezing or repeatedly needing to clear your throat
Hoarseness, especially in the morning

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A doctor should be consulted if the signs and/or symptoms do not subside after a few days, are accompanied with flu-like symptoms, do not lessen after treating with over-the counter antacids, and/or make eating food difficult.

Diagnosis of Erosive Esophagitis

Upper endoscopy – Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat, to examine the inside of your esophagus and stomach. Test results can often be normal when reflux is present, but an endoscopy may detect inflammation of the esophagus (esophagitis) or other complications. An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett’s esophagus.
Endoscopy – Endoscopy, the looking down into the stomach with a fibre-optic scope, is not routinely needed if the case is typical and responds to treatment. It is recommended when people either do not respond well to treatment or have alarm symptoms, including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes.Some physicians advocate either once-in-a-lifetime or 5- to 10-yearly endoscopy for people with longstanding erosive esophagitis to evaluate the possible presence of dysplasia or Barrett’s esophagus.
Ambulatory acid (pH) probe test – A monitor is placed in your esophagus to identify when, and for how long, stomach acid regurgitates there. The monitor connects to a small computer that you wear around your waist or with a strap over your shoulder. The monitor might be a thin, flexible tube (catheter) that’s threaded through your nose into your esophagus, or a clip that’s placed in your esophagus during an endoscopy and that gets passed into your stool after about two days.
Esophageal manometry – This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus.
X-ray of your upper digestive system – X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach and upper intestine.
A special X-ray called a barium swallow radiograph – can help doctors see whether liquid is refluxing into the esophagus. It can also show whether the esophagus is irritated or whether there are other abnormalities in the esophagus or the stomach that can make it easier for someone to reflux. With this test, the person drinks a special solution (barium, a kind of chalky liquid); this liquid then shows up on the X-rays.
A gastric emptying scan – can help show whether a person’s stomach is emptying too slowly, which can make reflux more likely to happen. This test is done either by drinking milk that has a tracer in it or eating scrambled eggs that have a tracer mixed in. A special machine that doesn’t use radiation can detect the tracer to see where it goes and how fast it empties the stomach.
Eosinophilic inflammation (usually due to reflux) – The presence of intraepithelial eosinophils may suggest a diagnosis of eosinophilic esophagitis (EE) if eosinophils are present in high enough numbers. Less than 20 eosinophils per high-power microscopic field in the distal esophagus, in the presence of other histologic features of erosive esophagitisis more consistent with erosive esophagit is than EE.
Barium swallow – An X-ray test that outlines the esophagus.
Cardiac evaluation – To check for heart disease.
Esophageal manometry or motility studies – To check the squeezing motion of your esophagus when you are swallowing.
Esophageal pH monitoring – Uses electrodes to measure the pH (acid level) in the esophagus. It is usually done over a 24-hour period.
Ambulatory acid (pH) test – (monitors the amount of acid in the esophagus)
Esophageal impedance test – (measures the movement of substances in the esophagus)
Esophageal manometry – This checks how well your esophagus works and whether the lower esophageal sphincter (the valve leading to the stomach) opens and closes the way it should. A tiny tube goes through your nose and down through your food pipe into the stomach. Then you rest on your side and swallow a sip of water. The tube is sensitive to pressure and measures how strong your muscles are and how well they work.
Esophago gastroduodenoscopy (EGD) –This is a biopsy of your esophagus. They put you under light anesthesia and insert a small tube down your throat through your mouth. There is a camera on the end so that the doctor can see what your esophagus looks like. In most cases, they will take a piece of tissue from your esophagus, which is called a biopsy.
Lab tests – If you have a biopsy done, the tissue sample will be sent to a lab to check for things such as infection, white blood cells, or esophageal cancer or precancerous cells.
Esophageal X-ray –This is also called an upper GI series or barium X-ray. You will swallow barium (as a liquid or pill) and they will take X-ray images of your neck, chest and stomach to check the esophagus for damage or to search for other esophagus problems, like hernia or tumors.

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Grades of esophagitis

There are number of grading systems used to evaluate the severity of the disease. Savary-Miller and the Los Angeles Classification System are two of the commonly used grading systems.

Savary-Miller:

Grade I: one or more supravestibular, non-confluent reddish spots, with or without exudate
Grade II: erosive and exudative lesions in the distal esophagus which may be confluent, but not circumferential
Grade III: circumferential erosions in the distal esophagus, covered by hemorrhagic and pseudomembranous exudates
Grade IV: presence of chronic complications such as deep ulcers, stenosis, or scarring with Barrett’s metaplasia

Los Angeles Classification System grades reflux esophagitis

Grade A: One (or more) mucosal break no longer than 5 mm that does not extend between the tops of two mucosal folds
Grade B: One (or more) mucosal break more than 5 mm long that does not extend between the tops of two mucosal folds
Grade C: One (or more) mucosal break that is continuous between the tops of two or more mucosal folds but which involve less than 75% of the circumference
Grade D: One (or more) mucosal break which involves at least 75% of the esophageal circumference

Treatment of Erosive Esophagitis

Treatment for esophagitis depends on its cause. Possible treatments include:

Medications that block acid production such as heartburn drugs.
Antibiotics, anti-fungals, or antivirals to treat an infection.
Pain medications that can be gargled or swallowed.
Corticosteroid medication to reduce inflammation.
Intravenous (by vein) nutrition to allow the esophagus to heal and to prevent dehydration and malnutrition.
Endoscopy to remove any lodged pill fragments.

There are several medications that can be used to treat erosive esophagitis They include:

Over-the-counter acid buffers — Buffers neutralize acid. They include Mylanta, Maalox, Tums, Rolaids, and Gaviscon. The liquid forms of these medications work faster But the tablets may be more convenient.Antacids that contain magnesium can cause diarrhea. And antacids that contain aluminum can cause constipation. Your doctor may advise you to alternate antacids to avoid these problems. These medicines work for a short time and they do not heal the inflammation of the esophagus.
Over-the-counter proton pump inhibitors — Proton pump inhibitors shut off the stomach’s acid production.Proton pump inhibitors are very effective. They can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are more potent acid-blockers than are H2 blockers, but they take longer to begin their effect.
Proton pump inhibitors – should not be combined with an H2 blocker. The H2 blocker can prevent the proton pump inhibitor from working.These are prescribed at higher doses than those available in over-the-counter forms.
Motility drugs – These medications may help to decrease esophageal reflux. But they are not usually used as the only treatment . They help the stomach to empty faster, which decreases the amount of time during which reflux can occur.
Mucosal protectors – These medications coat, soothe and protect the irritated esophageal lining. One example is sucralfate (Carafate).

Over the counter and prescription medicines

You can buy many GERD medicines without a prescription. However, if you have symptoms that will not go away, you should see your doctor.

Antacids – Doctors often first recommend antacids to relieve heartburn and other mild GER and GERD symptoms. Antacids include over-the-counter medicines such as. Antacids can have side effects, including diarrhea and constipation.

H2 blockers – H2 blockers decrease acid production. They provide short-term or on-demand relief for many people with erosive esophagitis symptoms. They can also help heal the esophagus, although not as well as other medicines. You can buy H2 blockers over-the-counter or your doctor can prescribe one. Types of H2 blockers include

Proton pump inhibitors (PPIs) – PPIs lower the amount of acid your stomach makes. PPIs are better at treating erosive esophagitis symptoms than H2 blockers. They can heal the esophageal lining in most people with erosive esophagitis. Such as

Talk with your doctor about taking lower-strength omeprazole or lansoprazole, sold over the counter.

Antibiotics – Antibiotics, including erythromycin , can help your stomach empty faster. Erythromycin has fewer side effects than prokinetics; however, it can cause diarrhea.

Prokinetics – Prokinetics help your stomach empty faster. Prescription prokinetics include

Both of these medicines have side effects, including

nausea
diarrhea
fatigue, or feeling tired
depression
anxiety
delayed or abnormal physical movement

Prokinetics can cause problems if you mix them with other medicines, so tell your doctor about all the medicines you’re taking.

Prevention & Self care of Erosive Esophagitis

General Self-Care

Take small bites of food, chew thoroughly (especially meats and firm vegetables) and drink plenty of water with pills or meals.
Ask your physician if you can crush any pills that you take, or if liquid versions are available.
Go to the emergency room for help dislodging any food that you cannot swallow or remove within one hour, or any stuck food that makes it hard to breathe. They can use a small tube to help remove the food or push it down into your stomach.
Don’t smoke.
Avoid medications that can cause or worsen esophagitis. Let your pharmacist and health care professional know about your diagnosis any time you get a new prescription or need to take an over-the-counter pill.
Follow the steps for reflux self-care no matter what type of diagnosis you have, so that any acid reflux you may have will not make your condition worse.

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Reflux Esophagitis Self-Care of Erosive Esophagitis

Avoid food and drinks that can aggravate acid reflux. Consider following a diet to reduce acid reflux or another esophagitis diet plan you develop with your health care provider.
Eat several small meals throughout the day instead of two or three large meals.
Stay upright for three hours after eating.
Insert a wedge under the top of your bed (pillows don’t do the trick) to elevate your head at least 6 inches while you sleep.
Limit alcohol intake.
Lose excess weight.
Consider herbal remedies to relieve or prevent heartburn and reflux, such as licorice, chamomile, slippery elm, marshmallow and more. Because these may interact with medications, always check with your doctor before using a new herb or supplement.
Reduce stress and anxiety by exercising or using relaxation techniques to help reduce your reflux.
Ask your health care provider whether acupuncture is safe for you. Provided you have no health reasons to avoid it, acupuncture may help reduce regurgitation and heartburn.

Eosinophilic Esophagitis Self-Care

Avoid the allergens causing your inflammation. If you do not know which foods or environmental allergens have caused your condition, ask your doctor about allergy testing. You can also work with a dietitian or allergist to do a formal elimination diet.
Follow the steps for naturally managing reflux esophagitis as well, since many people with eosinophilic esophagitis also experience some GERD symptoms that can make their condition worse.
Ask if you could benefit from an elemental diet, which replaces food with an amino acid-based formula.

Drug-Induced Esophagitis Self-Care

Drink an entire glass of water each time you take a pill (including supplements and vitamins), unless your doctor tells you not to.
Stay upright (sit or stand) for 30 minutes or more after taking a pill. This helps the pill reach your stomach and helps your saliva clear any residue from your esophagus.
Ask your health care provider if you can stop or temporarily discontinue any medications you are on that may be causing the problem. You can also ask if a different medication can be taken or if a liquid version is available.

Infectious Esophagitis Self-Care

Consider taking a general multivitamin to make sure you do not have micronutrient deficiencies.
Ask your doctor if the top supplements that are believed to boost immunity may be beneficial for you. Popular choices include echinacea, ginger, probiotics, vitamin D and more.
According to the specialist you can also obtain immune system benefits from getting plenty of vitamins C, B6, and E in your diet. Do this by eating plenty of green leafy vegetables, citrus fruits, salmon, tuna, chicken, chick peas, nuts and seeds.

Ask your health care provider if you might benefit from dietary changes, such as an anti-inflammatory diet or a diet to help reduce yeast.

Dietary changes that may reduce inflammation include avoiding fried foods, refined carbohydrates, red meat, sugar-sweetened drinks, and animal fats.
Berries, nuts, seeds, fatty fish, olive oil, tomatoes and green leafy vegetables are believed to reduce inflammation.
Dietary changes to fight yeast overgrowth, in case your infection is related to yeast, include changes called the candida diet. Changes include following a low-sugar diet, using coconut oil as a mouthwash, and eating probiotics.
Stay hydrated and get plenty of rest to help you fight your infection.
Ask your doctor if any immunosuppressant drugs you are taking can be reduced or eliminated.
Follow the natural treatment recommendations for reflux esophagitis as well.