Erosive esophagitis is visible damage to the lining of your esophagus caused by stomach acid washing back up from your stomach. Unlike ordinary acid reflux, where the tissue looks normal despite symptoms, erosive esophagitis means the acid has actually worn away patches of the esophageal lining, creating what doctors call mucosal breaks: small erosions or ulcers visible during an endoscopy. It’s a more advanced form of gastroesophageal reflux disease (GERD), and standard acid-suppressing medications heal it in 75 to 95% of cases within eight weeks.
How Stomach Acid Damages the Esophagus
Your esophagus is separated from your stomach by a ring of muscle called the lower esophageal sphincter. Normally, this sphincter opens to let food through, then closes tightly. In people with erosive esophagitis, this valve has decreased tone or relaxes too frequently, letting acid flow upward into the esophagus. The esophageal lining isn’t built to handle acid the way stomach tissue is, so repeated exposure gradually breaks down the surface.
Your body has built-in defenses: rhythmic muscle contractions push refluxed acid back down, and saliva neutralizes small amounts of acid. When those defenses can’t keep up with the volume or frequency of reflux, the acid erodes the tissue. A hiatal hernia, where part of the stomach pushes up through the diaphragm, weakens the sphincter further and significantly raises the risk.
Symptoms You Might Notice
The classic symptoms are heartburn (a burning sensation behind the breastbone) and acid regurgitation, where stomach contents rise into the throat. But here’s something surprising: in one Korean study of nearly 300 people with confirmed erosive esophagitis, about 75% had no typical reflux symptoms at all. Their erosions were discovered incidentally during an endoscopy done for other reasons. This means the condition can silently damage the esophagus without the burning or sour taste many people expect.
When symptoms do occur, they often include chest pain, a sour or bitter taste in the mouth, difficulty swallowing, and a sensation of food getting stuck. Some people notice their symptoms worsen after meals, when lying down, or at night.
How It Differs From Non-Erosive Reflux
Not everyone with acid reflux has visible damage. Non-erosive reflux disease (NERD) causes the same heartburn and regurgitation, but the esophageal lining looks completely normal on endoscopy. These are two distinct presentations of GERD, and the risk profiles differ. People with erosive esophagitis tend to have a higher body mass index, larger waist-to-hip ratio, and higher triglyceride levels. They’re also more likely to have a hiatal hernia, and men are about four times more likely than women to develop erosive disease rather than the non-erosive type.
The distinction matters because erosive esophagitis carries a higher risk of complications and typically requires longer treatment.
Risk Factors
Several factors raise your chances of developing erosive esophagitis, and many of them are modifiable:
- Excess weight: Obesity, particularly abdominal fat, increases pressure on the stomach and promotes reflux.
- Smoking: Current smokers have roughly 2.4 times the risk of erosive esophagitis compared to people who have never smoked. Heavy, long-term smokers (20+ pack-years) face about three times the risk. Even after quitting, elevated risk persists for about a decade.
- Alcohol use: Regular drinking is independently associated with erosive disease.
- Hiatal hernia: This is one of the strongest risk factors, increasing the odds of erosive esophagitis roughly fivefold.
How Severity Is Graded
When a gastroenterologist performs an endoscopy and finds erosions, they classify the damage using the Los Angeles Classification system, which has four grades:
- Grade A: One or more erosions, each 5 mm or smaller, confined within a single fold of tissue.
- Grade B: Erosions longer than 5 mm, still confined within individual folds.
- Grade C: Erosions that bridge across folds but cover less than 75% of the esophagus’s circumference.
- Grade D: Erosions covering 75% or more of the circumference.
Grades A and B are considered mild to moderate. Grades C and D are severe and need more aggressive, longer-term treatment. This grading system guides every treatment decision that follows.
Treatment and Healing
Proton pump inhibitors (PPIs), the class of medication that includes omeprazole and similar drugs, are the standard treatment. These work by sharply reducing the amount of acid your stomach produces, giving the esophageal lining time to heal. For Grade A and B disease, the American College of Gastroenterology recommends taking a PPI once daily for eight weeks. That course heals the erosions in 75 to 95% of people regardless of the specific PPI used.
Grade C and D disease typically requires a longer treatment course or ongoing maintenance therapy. After the erosions have healed, maintenance treatment commonly continues for six to twelve months to prevent relapse. For people whose symptoms don’t respond to a standard dose, doubling the PPI dose or adding a nighttime acid blocker from a different drug class can improve results.
A newer class of acid-suppressing drugs has shown promise. These medications work through a different mechanism than PPIs and suppress acid more quickly and consistently. In clinical trials, they maintained healed erosive esophagitis in about 85 to 87% of patients at six months, compared to 75% with a standard PPI. The lower dose showed a similar side-effect profile to the older medication, while the higher dose had slightly more side effects.
Complications of Untreated Disease
Left untreated, chronic acid exposure can lead to progressively serious problems.
Esophageal Strictures
Repeated cycles of injury and healing cause scar tissue to build up in the esophageal wall. Over time, this fibrosis narrows the opening. The hallmark symptom is difficulty swallowing solid foods that gradually worsens, sometimes progressing to trouble with soft foods and liquids. Food impaction, chest pain, and unintentional weight loss can follow.
Barrett’s Esophagus
In a community-based study that followed patients for five years, people with erosive esophagitis at the start had a fivefold increased risk of developing Barrett’s esophagus compared to people without reflux disease. Barrett’s is a condition where the normal esophageal lining is replaced by tissue that resembles the intestinal lining, and it’s considered a precursor to esophageal cancer. In the study, about 9% of erosive esophagitis cases progressed to Barrett’s over the follow-up period, and another 13% worsened in severity grade.
Warning Signs That Need Prompt Evaluation
Most acid reflux can be managed initially without an endoscopy. But certain symptoms signal that something more serious may be happening and warrant a scope. These red flags include difficulty swallowing, unintentional weight loss, gastrointestinal bleeding (which can show up as dark stools or vomiting blood), persistent nausea or vomiting, unexplained anemia, and chest pain that’s been ruled out as a heart problem. If your reflux symptoms don’t improve after a trial of acid-suppressing medication, or if they return as soon as you stop treatment, that also warrants endoscopic evaluation to determine whether you have erosive disease and how severe it is.