When should a patient with a history of upper gastrointestinal (GI) endoscopy showing hernia, incompetent lower esophageal sphincter, esophagitis, gastritis, subcardial erosions, antral ulcers, and duodenitis undergo a follow-up endoscopy?

From the Guidelines

The patient should undergo a follow-up endoscopy in approximately 8 weeks after completing appropriate treatment for the identified conditions, as recommended by the American College of Physicians 1. This timing allows for adequate healing of the esophagitis, gastric inflammation, erosions, and duodenal inflammation noted on the January 2,2024 endoscopy. Before the repeat procedure, the patient should complete a full course of proton pump inhibitor therapy (such as omeprazole 40mg daily or equivalent) for 8 weeks, along with testing and treatment for H. pylori if present. The follow-up endoscopy is necessary to confirm healing of the erosions and ulcerations, assess improvement in the inflammation, and ensure there are no persistent or new concerning findings. Key considerations for the follow-up endoscopy include:

• Confirmation of healing of the esophagitis and erosions
• Assessment of improvement in gastric and duodenal inflammation
• Evaluation for any new or persistent concerning findings, such as Barrett esophagus or dysplasia
• Adjustment of treatment plans as needed based on the findings of the follow-up endoscopy. It is essential to note that the patient's symptoms and response to treatment will guide the timing of the follow-up endoscopy, with some patients requiring earlier or later follow-up based on their individual needs 1.

From the Research

Follow-up Endoscopy

The patient's upper GI endoscopy on 1/2/2024 revealed several findings, including a hernia, incompetent lower esophageal sphincter, lower end oesophagitis, and superficial ulcers in the stomach and duodenum. To determine when the next endoscopy should be performed, we can look at the following guidelines:

• In confirmed erosive or non-erosive reflux disease, follow-up endoscopy is indicated only in the presence of complications or Barrett's esophagus 2.
• For patients with gastric ulcer or complicated duodenal ulcer, monitoring by endoscopy is mandatory 2.
• There is no consensus regarding the indication for follow-up biopsy in confirmed endemic sprue 2.

Treatment and Follow-up

The patient's treatment plan may involve proton pump inhibitors (PPIs), H2-receptor antagonists, or prokinetics. Studies have shown that:

• PPIs are more effective than H2RAs in relieving heartburn in patients with GORD who are treated empirically and in those with ENRD 3.
• The risk ratio for heartburn remission for PPI versus placebo was 0.37 in empirical treatment of GORD and 0.71 in treatment of ENRD 3.
• Vonoprazan, a new potassium-competitive acid blocker, has been shown to be effective in healing GERD, particularly in patients with severe erosive esophagitis 4.

Next Steps

Based on the patient's findings and the guidelines above, the next endoscopy should be scheduled:

• If the patient has complications or Barrett's esophagus, follow-up endoscopy is indicated 2.
• If the patient has a gastric ulcer or complicated duodenal ulcer, monitoring by endoscopy is mandatory 2.
• The patient's treatment plan and response to treatment should be taken into account when scheduling the next endoscopy 5, 6, 3. Some key points to consider when deciding on the timing of the next endoscopy include:
• The severity of the patient's symptoms and findings
• The patient's response to treatment
• The presence of complications or Barrett's esophagus
• The need for monitoring and follow-up care 4, 5, 2, 6, 3.