Erosive esophagitis

Inflammation of the inner wall of the esophagus (Latin: oesophagus), which is accompanied by erosion (Latin: erosio) of the mucosa lining it, is defined as erosive esophagitis. [1]

Epidemiology

Erosive esophagitis is estimated to affect 1% of the adult population.

According to clinical studies, erosive esophagitis is found in 40-65% of patients with gastroesophageal reflux disease, with a prevalence of up to 15-22% (30-35% in North and Latin America and up to 45% in Arab countries). [2]

Causes of the erosive esophagitis

As a morphologic form of the inflammatory process in the esophagus erosive esophagitis is one of the serious complications of gastroesophageal reflux disease (GERD), and some experts even consider it a severe form of this disease, in which - due to the decreased tone of the lower esophageal sphincter (ostium cardiacum) - there is a retrograde throwing (reflux) of gastric contents into the esophagus. Therefore, erosive inflammation of the esophagus with recurrent gastroesophageal reflux is also called reflux esophagitis.

In addition, the causes of inflammation leading to esophageal erosion, are attributed to the presence of:

• Diaphragmatic hernia - a hernia of the esophageal opening of the diaphragm (hiatus oesophageus), which most often forms with increased intra-abdominal pressure;
• chemical burns to the esophageal mucosa;
• Hypo- and hypermotor esophageal dyskinesia;
• Esophageal peristalsis abnormalities with esophageal retention of food bolus in achalasia of cardia.

Erosive esophagitis in a child may be the result of: congenital esophageal enlargement (megaesophagus), leading to frequent regurgitation (regurgitation) of food and its retention in the esophagus; damage to the mucosa by foreign bodies of the esophagus, as well as its infectious lesions in viral or bacterial pharyngitis, laryngitis or tonsillitis. Read more - Chronic esophagitis in children

Risk factors

Smoking and alcohol; junk food (spicy and fatty); flatulence and obesity; xerostomia (insufficient saliva production); lazy stomach syndrome; chronic form of gastritis with Helicobacter pylori infection (H. Pylori) or cytomegalovirus gastritis; gastric ulcer; problems with the gallbladder (chronic cholecystitis, cholelithiasis) and bile outflow; radiation and chemotherapy for cancer, and kyphosis of the thoracic spine experts are considered risk factors for erosive esophageal inflammation. [3]

Pathogenesis

In gastroesophageal reflux disease the pathogenesis of erosive inflammation is caused by aggressive action of hydrochloric acid, proteolytic enzymes of gastric juice (protein-degrading pepsins) and bile on cells of the mucosa lining the esophagus (tunica mucosa), which is formed by lamina muscularis mucosae - muscular plate, lamina propria mucosae - intrinsic plate and inner lining of non-keratinizing (not undergoing keratinization) multilayered squamous epithelium. Its cells are arranged in layers on the basal membrane. In this case, the mucosa forms small transverse wavy folds.

The consequence of mucosal lesions is deformation and degeneration of its cells, expansion of the intercellular matrix with infiltration by neutrophilic granulocytes. Visualization of the mucosa reveals small nodular, granular or disc-shaped defects.

In severe cases, some parts of the inner wall of the esophagus are almost completely deprived of mucous membrane (up to the own plate and deeper) with the formation of ulcers.

Burn of esophageal mucosa with alkali causes deep liquefying necrosis of tissues with decomposition of proteins and lipids, and exposure to concentrated acidic leads to coagulation necrosis with further formation of scab.

Symptoms of the erosive esophagitis

In this disease, the first signs are manifested by an unpleasant sensation of a lump in the throat and often painful sensations in the back of the chest - during and after eating, when tilting the body forward or in a horizontal position of the body.

The list of clinical symptoms of erosive inflammation of the esophagus includes difficulty swallowing (dysphagia), pain when swallowing, hiccups and belching, nausea and vomiting (may be bloody), salivation (increased salivation) and halitosis, sudden chest pain with shortness of breath or fever, and decreased appetite. [4]

Types and degrees of erosive esophagitis

Specialists distinguish such types of erosive inflammation of the esophageal mucosa as:

• Acute erosive esophagitis, for more information see. - Acute esophagitis;
• Chronic erosive esophagitis when the disease lasts more than six months read - Chronic Esophagitis;
• Distal erosive esophagitis or terminal esophagitis affects the far (distal) or terminal - abdominal segment of the esophagus, which runs from the diaphragm to the cardiac part and the bottom of the stomach. This segment (8-10 cm long) descends through the right leg of the diaphragm at the level of the Th10 vertebra and passes into the cardia of the stomach at the level of Th11;
• Catarrhal erosive esophagitis - with edema and superficial damage to the tunica mucosa;
• Erosive-ulcerative esophagitis, in which a focus or several areas of ulceration of varying size and depth are formed on the esophageal mucosa;
• erosive peptic esophagitis or reflux esophagitis (caused by gastroesophageal reflux);
• Erosive-fibrinous esophagitis, in which inflammation is accompanied by scarring of the mucosa and increased formation of fibrous tissue;

Necrotizing or necrotizing erosive esophagitis - with diffuse necrosis of the esophageal mucosa in its chemical burns or acute radiation injury.

When assessing the extent of the lesion and its nature by endoscopic examination, the following are distinguished:

• Grade 1 erosive esophagitis - with single or multiple erosions (erythematous or exudative) on a single fold;
• Grade 2 erosive esophagitis - with multiple erosions that affect multiple folds and may merge;
• Grade 3 erosive esophagitis, in which multiple erosions merge (with islands of edematous tissue between them) and join around the circumference of the esophagus;
• 4 degree erosive esophagitis - with extensive lesions of the mucosa and deep ulcers.

The Los Angeles classification of erosive esophagitis (also on endoscopy) accepted by gastroenterologists is as follows.

Mild reflux esophagitis:

• Grade A: one or more erosions, limited to the folds of the mucosa and no more than 5 mm in size;
• degree B: one or more erosions, limited to the folds of the mucosa and the extent of more than 5 mm.
• Severe reflux esophagitis:
• Grade C: erosions extending into the mucosal folds but less than three-quarters of the circumference of the esophagus;
• Degree D: confluent erosions affecting more than three-quarters of the circumference of the esophagus.

Complications and consequences

When erosive esophagitis occurs, there can be serious complications and consequences, including:

• bleeding from erosions and ulcers, manifested by blood in vomit or stool;
• Scarring of the mucosa, which can lead to stricture (narrowing or thickening) of the esophagus and decreased esophageal patency;
• esophageal ulcer;
• pathological change in the structure of the epithelium of the lower esophageal mucosa with the formation of Barrett's esophagus and the threat of its malignization to adenocarcinoma or squamous cell cancer.

Diagnostics of the erosive esophagitis

All details in the publication - Diagnosis of chronic esophagitis

The main blood tests are general and leukocytic formula; a urease test for H. Pylori is performed, as well as histological examination of a biopsy of the esophageal mucosa.

Instrumental diagnostics include: barium x-ray and esophageal endoscopy, pH-metry, etc. Read more - Esophageal examination

Differential diagnosis

Differential diagnosis should exclude other morphologic forms of esophagitis, esophageal diverticulum and scleroderma, lesion of the esophagus in the ileum and colon in Crohn's disease, etc.

Treatment of the erosive esophagitis

The drug treatment prescribed by doctors includes drugs from several pharmacological groups.

Antacid medications:

• Almagel, Fosfalugel, Maalox, Ajiflux and others.

Drugs of the group of proton pump inhibitors:

• Omeprazole (Omez, Zolcer); Esomeprazole or Nexium; Pantoprazole, Panum, Panocid, or Zolopent, Rabeprazole and others.
• H2-histamine receptor blockers, e.g., Famotidine

Good nutrition is very important and there is a diet for erosive esophagitis and a menu for erosive esophagitis. [5], [6] Full details:

• Diet for esophagitis
• Diet for reflux esophagitis

Read - Physical therapy for reflux esophagitis

Apply folk treatment of erosive esophagitis is possible only in its mild form, for which it is recommended: drink juice from raw potatoes and carrots, take a herbal decoction (of linden flower, chamomile apothecary, horsetail, narrow-leaved cypress, water pepper, veronica and calendula medicinal, hernia naked, bird's throat). In addition, you can take a teaspoon of sea buckthorn or linseed oil daily for two to three weeks.

Prevention

With proper nutrition, normalization of weight, treatment of GERD and other gastroenterological diseases, the threat of erosive inflammation of the esophagus is significantly reduced.

Forecast

In the case of esophagitis of all morphological forms, the prognosis depends directly on both the cause of inflammation of the inner wall of the esophagus and the degree and depth of damage to its mucosa, as well as the presence/absence of complications. Usually esophagitis caused by gastroesophageal reflux disease is well amenable to medical treatment.

And taking into account these factors, a special medical commission decides the question - whether erosive esophagitis and the army are compatible - in each specific case.