Oesophagitis

What is oesophagitis?

Oesophagitis means inflammation of the lining of your oesophagus (gullet), the tube that carries food from your mouth to your stomach. Most cases happen when acid from your stomach leaks upwards and irritates this lining, a process called acid reflux.

What are the symptoms of oesophagitis?

The main symptom is heartburn, a burning feeling that rises from your upper abdomen or lower chest towards your neck. Despite the name, this has nothing to do with your heart. Other common symptoms include:

• pain in your upper abdomen or chest
• feeling sick, or an acid taste in your mouth
• bloating, belching and indigestion
• a burning pain when swallowing hot drinks
• food occasionally feeling like it is sticking as you swallow

Like heartburn, these symptoms tend to come and go and are often worse after a meal. Less commonly, oesophagitis can cause a persistent cough, especially at night, hoarseness, bad breath, a sore throat, or a feeling of a lump in your throat. A small number of people have severe chest pain, which can be mistaken for a heart attack.

What causes oesophagitis, and who is at risk?

There is a circular band of muscle, called a sphincter, at the junction between your oesophagus and stomach. It normally relaxes to let food down, then tightens to stop food and acid leaking back up. Oesophagitis usually develops when this sphincter does not work as well as it should, letting acid reflux upwards and irritate the lining of your oesophagus, which has little natural protection against it.

It is not always clear why the sphincter weakens. Sometimes there is an obvious reason, such as pressure in your stomach rising higher than the sphincter can withstand, for example during pregnancy, after a large meal, or when bending forward. Having a hiatus hernia, where part of your stomach pushes up into your chest through your diaphragm, also increases your chance of developing reflux.

Regular heartburn is more common in smokers, pregnant women, heavy drinkers, people who are overweight, and people aged 35 to 64. Certain foods and drinks can also trigger symptoms in some people, including:

• caffeine, alcohol and fizzy drinks
• spicy, fatty or fried foods, and chocolate
• peppermint, including chewing gum
• citrus fruits and juices, onions and tomatoes

Some medicines can also make symptoms worse or irritate your oesophagus directly, including anti-inflammatory painkillers such as ibuprofen or aspirin, and certain medicines for blood pressure, anxiety or asthma. Tell a doctor if you think a medicine is causing or worsening your symptoms.

About one adult in three has some heartburn every few days, and nearly one adult in ten has it at least once a day.

Are there different types of oesophagitis?

Reflux oesophagitis, caused by stomach acid, is by far the most common type. Other, less common types include:

• infectious oesophagitis, caused by a viral, fungal or bacterial infection, which is more likely if your immune system is weakened
• drug-induced oesophagitis, caused by a medicine irritating or damaging the lining, often because it was not taken with enough water
• eosinophilic oesophagitis, caused by a build-up of a type of white blood cell in the oesophagus, often linked to allergies
• caustic oesophagitis, caused by swallowing or breathing in a harsh, corrosive chemical.

Doctors also grade the severity of reflux oesophagitis seen on endoscopy, from mild, small breaks in the lining through to more extensive or long-standing damage.

How is oesophagitis diagnosed?

Many people are diagnosed with "presumed acid reflux" based on typical symptoms alone, especially if these ease with treatment. Further tests may be advised if your symptoms are severe, do not improve with treatment, or are not typical of reflux.

Gastroscopy (endoscopy) is the main test. A thin, flexible tube with a camera and light is passed through your mouth, throat and oesophagus, letting the doctor or nurse see any redness, inflammation or ulceration directly, and take a small tissue sample (biopsy) if needed. A normal-looking oesophagus does not rule out reflux, as some people are very sensitive to small amounts of acid.

If the diagnosis is not clear, you may also have a test to check the acidity inside your oesophagus over 24 hours, or other tests such as a barium swallow (an X-ray taken after drinking a special liquid) or heart tracings, to rule out other conditions.

How is oesophagitis treated?

Non-surgical treatment

Lifestyle changes are often advised alongside medicine, although there is limited research on exactly how much they help. These include:

• stopping smoking, since chemicals in cigarettes relax the sphincter muscle
• losing weight, if you are overweight, since extra pressure on your stomach encourages reflux
• eating smaller meals, and avoiding food in the three hours and drinks in the two hours before bed
• raising the head of your bed by 10 to 20cm, for example using blocks under the legs, rather than extra pillows
• trying to avoid, one at a time, any specific foods or drinks that seem to trigger your symptoms

Medicines used to treat oesophagitis include:

• antacids, which are alkaline liquids or tablets that give quick relief for mild or occasional heartburn
• proton pump in hibitors (PPIs), which reduce the amount of acid your stomach makes and are usually tried first
• H2 blockers (histamine receptor blockers), an alternative type of acid-suppressing medicine
• prokinetic medicines, which speed up how quickly food passes through your stomach and can help with bloating or belching, though they are not recommended for long-term use.

A common approach is a full-dose course of a PPI for about a month to settle symptoms and let any inflammation heal, then stepping down to the lowest dose that controls your symptoms, or back to antacids as needed. Some people need long-term daily treatment, which is considered safe, with side effects being uncommon.

Surgical treatment

Surgery is not usually needed. An operation to tighten the lower oesophagus and stop acid leaking upwards can be done using keyhole surgery, but its success is generally no better than acid-suppressing medicine. It may be considered if your quality of life is significantly affected and medicines are not working well, or you do not want to take them long-term. If oesophagitis has caused a stricture (a narrowing of the oesophagus), a doctor can also widen this using a procedure called dilation.

When should I see a doctor?

See your doctor if your symptoms are frequent, severe, or are not improving with over-the-counter treatment.

Tell your doctor if you have pain or difficulty swallowing, or food feels like it is sticking, as this can be an early sign of a complication such as a stricture. Long-standing, severe inflammation can also lead to changes in the cells lining the oesophagus, called Barrett’s oesophagus, which slightly raises the risk of oesophageal cancer, so it is worth getting persistent or worsening symptoms checked. Seek urgent medical help for severe chest pain, as this can sometimes be mistaken for a heart attack.