The esophagus is a muscular tube that connects the mouth to the stomach.

In people with GERD, the most common site of injury is the lining of the lower part of the esophagus, at the junction where the esophagus and stomach meet. The protective lining erodes over time. When that layer is completely worn away, the muscular layers of the esophagus are more susceptible to damage from stomach acid. This injury to the esophagus is called an esophageal ulcer.

This article will review what causes esophageal ulcers, as well as the symptoms, diagnostic process, and treatment options.

Causes

An esophageal ulcer is a sore or distinct break in the tissue that lines the esophagus. The most common causes of esophageal ulcers are:

• Acid reflux associated with GERD
• Esophagitis caused by medication or infection. Viral, bacterial, and fungal infections, such as candida species, herpes simplex, human immunodeficiency virus (HIV), and cytomegalovirus, can cause inflammation of the esophagus, especially in immunocompromised individuals prone to opportunistic infections. Pill-induced esophagitis may result from prolonged contact of non-steroidal anti-inflammatory drugs (NSAIDS), bisphosphonates, and some antibiotics (like doxycycline, an antibiotic frequently used to treat acne).
• Caustic Injury
• Radiation (if the upper part of the body was exposed to radiation for treatment of cancer). This condition is called radiation esophagitis.

It was once thought that spicy food causes esophageal ulcers, but more recent research has disproved this theory, although it may exacerbate the symptoms of a current ulcer.

Symptoms

You may have an esophageal ulcer but experience no symptoms at all, but if you do, the most common symptom is a gnawing or burning sensation in the chest (heartburn) which can be mild or severe. Additional symptoms may include:

• Difficult or painful swallowing
• Pain that is lessened by eating, drinking, or taking antacids
• Nausea or vomiting
• Acid reflux or indigestion, usually characterized by heartburn or a burning sensation in the chest
• Dry cough (usually worse at night when you are laying flat during sleep)
• Atypical chest pain
• Weight loss due to food avoidance in people with severe symptoms

Diagnosis

Tests that may be used to diagnose diseases of the esophagus include barium X-rays (or barium swallow), upper endoscopy, and pH monitoring.

• During a barium swallow, X-rays are taken of the esophagus after a barium solution is swallowed.
• In an upper endoscopy, a tube with a camera and a light on the end is passed through the mouth and into the esophagus.
• During pH monitoring, the pH of the esophagus is measured with a special instrument that is passed into the esophagus.
  

Esophagogastroduodenoscopy (EGD), a special type of endoscopy, is the most effective way to diagnose an esophageal ulcer with direct visualization of the mucosa because it is more accurate than a barium X-ray and much simpler than exploratory surgery.

Still, despite being incredibly safe, some people are a bit apprehensive about the idea of "swallowing a scope." Fortunately, modern medical instruments and sedation have made this minimally invasive procedure one that is amongst the most well-tolerated.

It’s worth mentioning that blood tests to check for infection, such as HSV-1 and CMV in the esophagus, are always ordered if there is a suspicion of esophageal ulcers to rule out these rare causes. However, the most accurate way to check for these infections is to obtain biopsies (small samples from the lining of the esophagus) and send them for a special stain to detect the presence of the virus.

Treatment

The type of treatment that you will receive for your esophageal ulcer will depend on the cause.

If the cause is GERD, they may prescribe a proton pump inhibitor (PPI) based on the severity of your symptoms. Commonly prescribed PPIs include:

• Prevacid (lansoprazole)
• Nexium (esomeprazole)
• Protonix (pantoprazole)
• Aciphex (rabeprazole)
• Prilosec (omeprazole)

For milder symptoms, histamine receptor blockers (H2b) can be used. The most commonly used H2b is Pepcid (famotidine).

If you have a pill-induced ulcer, your healthcare provider may ask you to stop the drug that you are taking. Sometimes that may be enough to resolve your symptoms, and small ulcers may repair on their own over time. In addition, histamine-2 receptor blockers or PPIs may be prescribed to manage your symptoms if they linger or prescribe a different pain medication.

In rare cases, viruses or fungus can cause esophageal ulcers. In this case you may need to take antifungal or antiviral medications. Surgery is indicated in rare, severe cases that are characterized by perforation (hole in the esophagus) and refractory bleeding.

No matter the treatment regimen, it is important that you follow your healthcare provider's orders and take your medications as prescribed to increase your chance of fully healing.

Recovery

You may feel a swift resolution of your symptoms after treatment, but it is important that you complete your course of medication because chronic inflammation can lead to complications including bleeding, perforation or esophageal stricture (narrowing of the lumen of the esophagus) that may need esophageal dilation (a procedure used to stretch out the esophagus using upper endoscopy).

Also, neutralizing and decreasing stomach acid production in the stomach is integral to alleviating your symptoms. 

When to Call Your Healthcare Provider

If you experience any of the following symptoms, you may want to call your healthcare provider right away:

• Fever of 100.4° F ( 38.0°C) or higher
• Chills
• Pain or trouble swallowing
• Coughing up blood
• Severe belly pain (especially belly pain that is sharp and shooting)
• Frequent nausea or vomiting that looks like bloody coffee grounds
• Dark, tarry, or bloody stools. Dark stools can be indicative of hemorrhage, or internal bleeding that is discoloring your stool. 

Of note, mid-esophageal ulcers have a greater tendency to hemorrhage compared with ulcers at the gastroesophageal junction, but there is no way to know that based on your symptoms alone, so if you feel any chronic symptoms of chest pain, new or sudden belly or abdominal discomfort, or your heartburn is not relieved with medication seek immediate medical attention.

Dietary Changes

Foods to Eat

A diet high in fiber is especially beneficial to those with an esophageal ulcer. The following foods are easy on the digestive symptoms and may even help promote healing:

• Oats
• Legumes
• Non-citrus and high potassium fruits like apples and bananas
• Fish
• Lean protein
• Green leafy vegetables like broccoli, spinach, and kale

Foods to Avoid

Spicy foods, carbonated beverages, citrus fruits, and caffeine can irritate the esophageal lining, so these foods should be avoided. A diet high in junk and processed foods can raise stomach acid levels exacerbating your symptoms. 

Effective healing isn’t only about avoiding trigger foods, it’s also about making some necessary lifestyle changes. Following these guidelines can help you avoid exacerbating your symptoms while you heal:

• Take small bites of food and chew foods well.
• Avoid tough meats, fresh “doughy” bread or rolls, hard bread crust, and abrasive foods.
• Sip fluids when taking solids at meals and snacks to moisten foods.
• Stop eating when you start to feel full.
• Eat slowly in a relaxed atmosphere.
• Choose decaffeinated coffee, tea, or caffeine-free soft drinks.
• Sit upright when eating. Remain in a sitting position for at least 45-60 minutes after eating.
• Try to avoid eating for three hours before bedtime.
• Eat small, frequent meals and snacks.

Summary

An esophageal ulcer is a type of peptic ulcer that develops on the lining of your esophagus, often at the lower end where the esophagus and stomach connect. GERD is the most common cause of esophageal ulcers, and a burning sensation in the chest is often the first symptom that people experience.

A Word From Verywell

Esophageal ulcers are often the result of chronic GERD or infections, but there are a number of causes that may or may not cause symptoms. No two cases of esophageal ulcers are the same. Some people may take antibiotics and be on their way, while others may require surgery. Either way, esophageal ulcers are quite manageable thanks to advances in modern medicine.