What is the treatment for Grade D esophagitis?

Treatment for Grade D Esophagitis

Proton pump inhibitor (PPI) therapy at high doses is the first-line treatment for Grade D esophagitis, with twice-daily dosing recommended for 8-12 weeks to achieve optimal healing. 1, 2

Initial Treatment Approach

First-Line Therapy

• PPI therapy at high dose:
  • Recommended twice-daily dosing for 8-12 weeks 1, 3
  • Options include:
    • Omeprazole 20 mg twice daily 1
    • Esomeprazole 40 mg once or twice daily 4, 5
    • Lansoprazole 30 mg once or twice daily 2

Rationale for High-Dose PPI

• Grade D esophagitis represents severe erosive disease with extensive mucosal breaks
• Studies show healing rates of 80-90% with high-dose PPI therapy 2, 4
• Twice-daily dosing provides superior acid suppression compared to once-daily dosing 1, 3

Timing of PPI Administration

• PPIs should be taken 30 minutes before meals (preferably breakfast) for optimal efficacy 3
• For twice-daily dosing, the second dose should be taken before dinner 3

Assessment of Treatment Response

Follow-up Endoscopy

• Repeat endoscopy after 8-12 weeks of treatment is strongly recommended 1
• This is critical to:
  • Confirm healing of erosions
  • Rule out underlying Barrett's esophagus (present in up to 12% of patients after healing) 1
  • Assess for strictures that may have been underestimated initially 1

Management of Persistent Symptoms

• If dysphagia persists despite PPI therapy, consider:
  • Endoscopic evaluation for strictures or persistent inflammation 6
  • Endoscopic dilation for fibrostenotic disease 1

Maintenance Therapy

Long-Term PPI Treatment

• After initial healing, continuous daily PPI therapy is strongly recommended 1
• On-demand therapy is NOT appropriate for patients with history of Grade D esophagitis 1, 3
• Maintenance doses:
  • Can be reduced to standard once-daily dosing after confirmed healing 1, 3
  • Esomeprazole 20-40 mg daily has shown 93% maintenance of healing at 6 months 4

Duration of Maintenance Therapy

• Long-term (potentially indefinite) maintenance therapy is recommended 1
• Relapse rates are extremely high (>80% within 6 months) when treatment is discontinued 7

Additional Therapeutic Considerations

Endoscopic Dilation

• Indicated for patients with fibrostenotic disease and persistent dysphagia 1
• Can be performed using either balloon or bougie dilators 1
• Most effective when combined with PPI therapy 1

Lifestyle Modifications

• While not sufficient alone, these may complement PPI therapy:
  • Elevation of head of bed for nighttime symptoms 1
  • Weight loss if overweight/obese 1
  • Avoidance of meals 2-3 hours before bedtime 1

Important Caveats and Pitfalls

1. Do not use on-demand therapy for Grade D esophagitis - continuous therapy is essential 1, 3

2. Do not delay endoscopic follow-up - severe esophagitis may mask underlying Barrett's esophagus 1

3. Do not underestimate strictures - endoscopists frequently underestimate the frequency of strictures in severe esophagitis 1

4. Do not discontinue PPI therapy after healing - relapse rates approach 80-90% within 6 months 7, 4

5. Do not use H2-receptor antagonists as primary therapy - they are significantly less effective than PPIs for severe esophagitis 1, 2