Oesophagitis

The mucosa lining the oesophagus produces mucous to aid movement of food to the stomach and to provide some protection to the surface layer (epithelium) of the oesophagus. However, acid refluxing can wash away some of the mucosal protection and come into contact with the lining itself. This is highly concentrated hydrochloric acid; strong enough to be able to dissolve metal, if you were to spill some on your hand it was cause significant scarring - which it can also do to the oesophagus.

We may feel the acid burning as heartburn (though 48% of women and 22% of men with persistent acid reflux report never having felt it, as this 2023 study found).

Inflammation and scarring caused by the acid is called oesophagitis. Sometimes an endoscopist will classify the degree of oesophagitis observed using one of the following scales:

The Savary-Miller grading system is commonly used:

• • Grade 1: single or multiple erosions on a single fold. Erosions may ooze fluids or just show redness.

  • Grade 2: multiple erosions affecting multiple folds. Erosions may be joined together.

  • Grade 3: multiple circumferential erosions.

  • Grade 4: ulceration, narrowing or oesophageal shortening.

  • Grade 5: Barrett's epithelium. Columnar metaplasia in the form of circular or non-circular (islands or tongues) and extensions.

The more recent and more objective Los Angeles grades A to D classification is also used.

• • Grade A: one or more mucosal breaks no longer than 5 mm, none of which extends between the tops of the mucosal folds.

  • Grade B: one or more mucosal breaks more than 5 mm long, none of which extends between the tops of two mucosal folds.

  • Grade C: mucosal breaks that extend between the tops of two or more mucosal folds, but which involve <75% of the mucosal circumference

  • Grade D: mucosal breaks which involve ≥75% of the mucosal circumference

To permit oesophagitis to heal:

• Avoid any foods you have identified as a particular trigger for you.

• Take an acid suppressant: either an “H2 blocker” such as famotidine/Pepcid, or a “Proton Pump Inhibitor (PPI)" such as omeprazole/Prilosec.
  Note. These are powerful drugs that must be taken strictly in accordance with the printed patient information leaflet and for no longer than a couple of weeks without a doctor’s approval. It’s not that the drugs are harmful but they can mask the symptoms of oesophageal cancer.
  These medicines to not reduce reflux - they just make it less damaging.

• Reduce reflux by lifestyle modifications as described in this chapter: Reflux: Natural Remedies

Cells of Barrett's Oesophagus may be produced to protect against the acid erosion.

Mallory Wess tear

A Mallory-Weiss tear is a tear in the mucous membrane at the junction of the stomach and esophagus which may result from prolonged and forceful vomiting, coughing, excess alcohol consumption or convulsions.

It can cause bleeding from the upper gastrointestinal tract seen as bright red in vomit or in bloody stools.

It will usually heal on its own, but PPI medication can help. In severe cases, surgery will rarely be required.

Cameron Lesions

These are abrasions or ulceration at the diaphragmatic hiatus due to a hiatus hernia causing bleeding.

Causes

They can result from repetitive movement of a hiatus hernia with some of the stomach sliding up or down through the hiatus hole.

They can also be caused by excessive acid attack from gastro-oesophageal reflux.

Symptoms

Gastronitestinal bleeding seen as bloody vomit (haematemesis) or black tarry or bloody stools (melaena).

Anaemia caused by loss of iron resulting in tiredness.

They will be normally be found with endoscopy.

PPI treatment is usually sufficient to permit healing, plus iron supplementation if required.

In rare cases, surgical intervention may be required like argon plasma coagulation (APC) or hiatus hernia repair, e.g. with fundoplication.

Page updated 22 September 2024