Is a patient with reflux esophagitis (Los Angeles classification), a 2 cm hiatus hernia, chronic gastritis, and a gastric subepithelial lesion a candidate for endoscopic gastric fundoplication?

Endoscopic Gastric Fundoplication for Reflux Esophagitis LA A with Hiatus Hernia, Chronic Gastritis, and Gastric Subepithelial Lesion

A patient with reflux esophagitis LA grade A, a 2 cm hiatus hernia, chronic gastritis, and a gastric subepithelial lesion is not an ideal candidate for endoscopic gastric fundoplication based on current guidelines. 1

Assessment of GERD Severity and Candidacy for Intervention

GERD Classification

• Los Angeles grade A esophagitis is considered "borderline GERD" and not definitive evidence of gastroesophageal reflux disease according to current guidelines 1
• Conclusive GERD evidence requires Los Angeles grade B or higher esophagitis, and/or acid exposure time (AET) ≥6.0% on 2 or more days on pH monitoring 1
• The presence of LA grade A esophagitis alone does not meet criteria for definitive GERD diagnosis and requires additional testing to confirm pathologic acid exposure 1

Hiatal Hernia Considerations

• A 2 cm hiatus hernia is considered small and does not by itself indicate a severe GERD phenotype 1
• Large hiatal hernias (typically >3 cm), along with Los Angeles C or D esophagitis and extreme levels of acid exposure are indicators of more severe GERD phenotypes that may warrant invasive interventions 1
• Small hiatal hernias like the 2 cm one described typically produce no symptoms and often require no specific treatment 2

Management Algorithm for Borderline GERD

First-line Approach

• For patients with LA grade A esophagitis, medical management with PPI optimization should be attempted first 1
• Aggressive lifestyle modifications and weight management should be implemented 1
• If symptoms are controlled with medical therapy, patients should be weaned to the lowest effective dose and/or on-demand therapy with H2 blockers/antacids 1

Additional Considerations

• Before considering any anti-reflux procedure, patients with borderline GERD should undergo prolonged wireless pH monitoring off PPI therapy to confirm pathologic acid exposure 1
• Endoscopic or surgical anti-reflux interventions are typically reserved for patients with confirmed GERD (LA grade B or higher esophagitis and/or AET ≥6.0% on multiple days) who have failed optimized medical therapy 1

Gastric Subepithelial Lesion Management

• The presence of a gastric subepithelial lesion requires separate evaluation and management 1
• For gastric subepithelial lesions arising from the muscularis propria that are less than 2 cm in size, surveillance using EUS should be considered rather than immediate intervention 1
• The management approach depends on the specific type, size, and location of the subepithelial lesion 1
• Endoscopic gastric fundoplication may complicate future evaluation and management of the subepithelial lesion 1

Chronic Gastritis Considerations

• Chronic gastritis should be evaluated and treated separately from GERD management 3
• The presence of chronic gastritis may actually be inversely associated with pathologic acid exposure in some patients 4
• Addressing the gastritis etiology (H. pylori, NSAIDs, etc.) should be prioritized before considering anti-reflux procedures 3

Recommendation for This Patient

• The patient should first undergo optimization of PPI therapy and lifestyle modifications 1
• If symptoms persist despite optimized medical therapy, prolonged wireless pH monitoring off PPI should be performed to confirm pathologic acid exposure 1
• The gastric subepithelial lesion should be characterized with EUS and managed according to its specific features 1
• Only after confirming pathologic acid exposure and failure of optimized medical therapy should anti-reflux procedures be considered 1
• If an anti-reflux procedure is eventually warranted, surgical options may be more appropriate than endoscopic fundoplication given the presence of multiple gastric pathologies 1

Common Pitfalls to Avoid

• Proceeding with endoscopic gastric fundoplication without confirming pathologic acid exposure in a patient with only LA grade A esophagitis 1
• Overlooking the need to characterize and appropriately manage the gastric subepithelial lesion 1
• Failing to optimize medical therapy before considering invasive interventions 1
• Not considering how the presence of a subepithelial lesion might complicate or contraindicate endoscopic fundoplication 1