What is erosive esophagitis?

What is Erosive Esophagitis?

Erosive esophagitis is a condition characterized by visible mucosal breaks (erosions) in the esophageal lining caused by gastroesophageal reflux disease (GERD), where stomach acid exposure leads to T-lymphocyte infiltration and damage to the esophageal mucosa. 1, 2

Clinical Definition and Pathophysiology

• Erosive esophagitis occurs when refluxate from the stomach causes T-lymphocyte infiltration of the esophageal mucosa, resulting in visible mucosal breaks or erosions 2
• The condition represents objective evidence of acid-mediated mucosal injury and is a more advanced stage of reflux disease compared to non-erosive reflux disease (NERD) 1, 3
• Erosive findings on upper endoscopy, combined with elevated esophageal acid exposure time (AET >4.0%), constitute conclusive evidence of GERD 1

Grading System: Los Angeles Classification

• The Los Angeles (LA) classification system is the standard for grading erosive esophagitis severity in GERD patients 4, 5
• LA Grade B or higher represents confirmatory evidence of erosive reflux disease, with 100% of patients having objective GERD on pH monitoring 4
• LA Grade C or D indicates severe erosive disease requiring either continuous long-term PPI therapy or consideration of anti-reflux intervention 6, 4
• LA Grade A can be seen in healthy asymptomatic volunteers and is NOT considered evidence of erosive reflux disease, with only 17.6% having objective GERD 4

Critical Distinction from Other Forms of Esophagitis

• The LA classification should NOT be used for non-GERD causes of esophagitis, including eosinophilic esophagitis, infectious esophagitis, medication-induced esophagitis, or Crohn's disease-related esophagitis 4, 5
• Eosinophilic esophagitis requires ≥15 eosinophils per high-power field on biopsy and should be classified using the EREFS or I-SEE scoring systems instead 5
• Before applying the LA classification, non-GERD causes must be excluded through appropriate biopsies from both proximal and distal esophagus 5

Clinical Significance and Complications

• Although death from reflux disease is uncommon, significant morbidity and mortality from complications such as esophageal ulcer, stricture, and cancer can occur 3
• Barrett's esophagus (mainly short-segment) is detected in approximately 12% of patients with erosive esophagitis after healing with acid suppressive therapy 7
• The severity of LA classification correlates with GERD complications including stricture formation, bleeding risk, and Barrett's esophagus development 5

Diagnostic Approach

• Upper gastrointestinal endoscopy is the primary diagnostic modality for identifying and grading erosive esophagitis 1
• Esophageal acid exposure time (AET) is a key physiomarker, with AET >4.0% across at least one day of wireless pH monitoring (off PPI) reflecting elevated acid burden 1
• Patients with reflux symptoms undergoing endoscopy for Barrett's esophagus detection should be treated with acid suppressive therapy prior to endoscopy to enhance diagnostic yield 7

Treatment Implications

• Patients with erosive esophagitis (LA Grade B or greater) require at least single-dose, long-term PPI therapy and should not be weaned off acid suppression 1, 6
• Proton pump inhibitors are the standard treatment for erosive esophagitis in the United States, with healing rates exceeding 80% after 8 weeks of treatment 8, 2
• Severe erosive esophagitis (LA Grade C or D) requires indefinite long-term PPI therapy and/or consideration of invasive anti-reflux procedures 1, 6