From the Guidelines
The patient should undergo a follow-up endoscopy in approximately 8-12 weeks after completing appropriate treatment for the identified conditions, as indicated by the presence of severe erosive esophagitis and the need to assess healing and rule out Barrett esophagus 1. This timing allows for adequate healing of the esophagitis, gastric erosions, superficial ulcers, and duodenal inflammation. The treatment regimen should include a proton pump inhibitor (such as omeprazole 40mg daily or esomeprazole 40mg daily) for 8 weeks, along with sucralfate 1g four times daily before meals for 4-6 weeks to coat and protect the ulcerated areas. Some key points to consider in the management of this patient include:
- The presence of a hiatal hernia and incompetent lower esophageal sphincter, which may require ongoing monitoring and management to prevent complications such as esophageal stricture or Barrett esophagus 1.
- The need for surveillance evaluation in patients with a history of Barrett esophagus, with intervals no more frequently than 3 to 5 years in patients with no dysplasia 1.
- The importance of addressing symptoms such as dysphagia, bleeding, anemia, weight loss, and recurrent vomiting, which may indicate the need for more urgent intervention 1. The follow-up endoscopy is necessary to confirm healing of the lesions, especially the gastric and duodenal erosions, and to rule out any underlying malignancy that might have been obscured by inflammation during the initial examination. If symptoms resolve completely and the follow-up endoscopy shows significant improvement, further endoscopies may be scheduled annually or as clinically indicated to monitor the hiatal hernia and incompetent lower esophageal sphincter.
From the Research
Follow-up Endoscopy
The patient's upper GI endoscopy findings include hernia, incompetent lower esophageal sphincter, lower end oesophagitis, and red and inflamed gastric mucosa with subcardiac erosions and ulcers. To determine when the next endoscopy should be performed, we can look at the following evidence:
- The study 2 suggests that follow-up endoscopy is indicated only in the presence of complications or Barrett's esophagus in confirmed erosive or non-erosive reflux disease.
- The study 3 found that repeat endoscopies were performed 5 times for diagnostic or "second look" reasons, none of which changed the patients' diagnosis or treatment, indicating that repeat endoscopy may not be helpful in all cases.
- The study 4 recommends that patients with GERD symptoms combined with warning symptoms of malignancy and those with other main risk factors for esophageal adenocarcinoma should undergo endoscopy.
- The study 5 found that omeprazole 20 or 40 mg daily can heal gastroduodenal ulcers in patients receiving non-steroidal anti-inflammatory drugs, but does not provide guidance on follow-up endoscopy.
- The study 6 evaluated the diagnostic yield and predictors of malignancy in follow-up of gastric ulcers and found that malignancy yield from follow-up gastroscopy was 2%, suggesting that diagnostic yield of endoscopic follow-up may be low in ulcers with benign appearance and adequate histology.
Timing of Next Endoscopy
Based on the evidence, the timing of the next endoscopy will depend on the patient's specific condition and the presence of any complications or warning symptoms. Some possible considerations include:
- If the patient has complications or warning symptoms of malignancy, follow-up endoscopy may be indicated sooner rather than later 4.
- If the patient has a benign appearance and adequate histology, the diagnostic yield of endoscopic follow-up may be low, and follow-up endoscopy may not be necessary 6.
- If the patient is receiving treatment for their condition, such as omeprazole for gastroduodenal ulcers, follow-up endoscopy may be performed to confirm healing and exclude malignancy 5.
- The study 2 suggests that follow-up endoscopy is indicated only in the presence of complications or Barrett's esophagus in confirmed erosive or non-erosive reflux disease, which may be relevant to this patient's case.