What is the initial treatment for esophagitis?

Initial Treatment for Esophagitis

The initial treatment for esophagitis should be proton pump inhibitors (PPIs) at a dose of 20-40 mg twice daily for 8-12 weeks. 1, 2

Types of Esophagitis and Treatment Approach

Erosive Esophagitis (GERD-related)

• First-line therapy: PPI therapy (e.g., omeprazole 20-40 mg twice daily) for 8-12 weeks 3, 2
• PPIs are significantly more effective than H2-receptor antagonists for healing erosive esophagitis 4
• For severe erosive esophagitis (LA grades C/D), higher doses may be required initially 5
• Healing rates with omeprazole:
  • 20 mg daily: 87% for mild esophagitis, 67% for moderate esophagitis 5
  • 40 mg daily: 97% for mild esophagitis, 88% for moderate esophagitis 5

Eosinophilic Esophagitis (EoE)

• First-line options:
  1. PPI therapy: 20-40 mg twice daily for 8-12 weeks 3, 1
  2. Topical swallowed corticosteroids (if PPI fails) 3, 1
  3. Dietary therapy as an alternative approach 1
• Approximately 41.7% of EoE patients respond to PPI therapy 1
• Response assessment requires endoscopy with biopsy while on treatment 1

Treatment Algorithm

1. Initial Assessment:

   • Determine type of esophagitis through endoscopy and biopsy
   • Assess severity (mild, moderate, severe)

2. Initial Treatment:

   • Start PPI therapy (omeprazole 20-40 mg twice daily) for 8-12 weeks 3, 2
   • For adults with EoE: 20-40 mg PPI twice daily 1
   • For children with EoE: 1 mg/kg per dose, twice daily (maximum adult dose) 1

3. Reassessment after 8-12 weeks:

   • For erosive esophagitis: Repeat endoscopy to confirm healing
   • For EoE: Repeat endoscopy with biopsy (remission defined as <15 eosinophils/hpf) 1

4. If inadequate response:

   • For erosive esophagitis: Increase PPI dose or add H2-receptor antagonist
   • For EoE: Consider topical corticosteroids or dietary therapy 3, 1
   • For strictures: Consider endoscopic dilation 1

Maintenance Therapy

• Long-term PPI therapy is strongly recommended for patients with healed erosive esophagitis 3
• Maintenance therapy should be titrated to the lowest effective dose based on symptom control 3
• For EoE, maintenance therapy is necessary as spontaneous disease remission is uncommon 1
• Without maintenance therapy, recurrence rates of erosive esophagitis are high (82% within 6 months) 5

Potential Pitfalls and Caveats

1. Symptom-histology discordance: In EoE, symptoms may not correlate with histological activity, necessitating endoscopic assessment of response 1

2. Disease progression: Untreated esophagitis may progress to strictures, particularly in EoE 1

3. PPI dosing: Less than daily dosing is not recommended for maintenance therapy in patients with previous erosive esophagitis 3

4. Potassium-competitive acid blockers (P-CABs): While these newer agents provide rapid and potent acid inhibition, they are generally not recommended as first-line therapy for acid-related conditions due to cost and fewer long-term safety data 3

5. Long-term PPI use: Monitor for potential side effects including kidney problems, bone fractures, and certain types of lupus erythematosus 2

By following this evidence-based approach, most patients with esophagitis can achieve symptom relief and mucosal healing, preventing long-term complications such as stricture formation and improving quality of life.