Treatment of Esophagitis
Proton pump inhibitors (PPIs) should be considered as first-line treatment for esophagitis due to their high efficacy, good safety profile, and convenience. 1, 2
Types of Esophagitis and Initial Approach
- Esophagitis can be classified into different types, with the most common being reflux esophagitis and eosinophilic esophagitis (EoE) 3, 4
- For reflux esophagitis, PPIs such as lansoprazole or omeprazole are highly effective for healing and symptom relief 5, 6
- For eosinophilic esophagitis, treatment options include PPIs, topical corticosteroids, and dietary therapy 1, 2
Treatment Algorithm for Esophagitis
Step 1: Initial PPI Therapy
- Start with standard dose PPI therapy (e.g., lansoprazole 30 mg daily or omeprazole 20 mg daily) for 8-12 weeks 5, 6
- PPIs have shown superior healing rates compared to H2-receptor antagonists and placebo in reflux esophagitis 3, 5
- For EoE, PPIs should be given twice daily for at least 8-12 weeks before assessing histological response 1, 2
Step 2: Assess Response and Adjust Treatment
- If symptoms persist after 4-8 weeks of PPI therapy, consider:
- For reflux esophagitis, healing rates with lansoprazole reach 74.7% at 4 weeks and 83.7% at 8 weeks 5
Step 3: Treatment for Eosinophilic Esophagitis (EoE)
- Topical corticosteroids are highly effective for inducing histological and clinical remission in EoE 1
- Dietary elimination therapy is effective in both adults and children with EoE 1, 7
- Six-food elimination diet results in higher histological remission rates than two or four food elimination diets 1
- Support from an experienced dietitian is strongly recommended throughout the elimination and reintroduction process 1
Step 4: Management of Complications
- For fibrostenotic disease in EoE, endoscopic dilation is effective in improving symptoms 1, 2, 8
- Dilation can be performed using either balloon or bougie dilators 1, 2
- Clinical outcomes are better if therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids 1, 2
- For high-grade strictures, dilation before initiation of medical therapy has been well tolerated and effective 2
Monitoring and Follow-up
- After initiation of therapy, endoscopy with biopsy while on treatment is recommended to assess response, as symptoms may not always correlate with histological activity 1, 2
- Regular clinic visits are suggested to assess symptoms, compliance with therapy, and adverse effects 2
- For patients with EoE who respond to PPI therapy, regular clinical follow-up including future endoscopies with biopsy may be indicated as some patients may lose response over time 2
- For reflux esophagitis, maintenance therapy with PPIs may be necessary to prevent relapse, as studies show high relapse rates (82% by 6 months) after stopping treatment 9
Special Considerations
- Patients with EoE refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 1
- For children with EoE, dietary restriction or complete dietary elimination using an amino acid-based formula has shown significant improvement in both clinical symptoms and esophageal histology 7
- The goal of therapy should be aimed at improving symptoms, but in those with persistent esophageal eosinophilia, the decision to advance treatment should consider the degree of symptoms, patient age, presence of esophageal abnormalities, and patient preferences 2
Treatment Pitfalls to Avoid
- Do not rely solely on symptoms to guide treatment decisions, especially in EoE, as symptoms may not correlate with histological activity 1, 2
- Avoid monotherapy with dilation for EoE as it does not address the underlying inflammatory process 2
- Be aware that even a normally appearing esophagus on endoscopy can have EoE, so biopsy samples should be obtained regardless of endoscopic appearance 8
- Recognize that GERD and EoE may coexist, and some patients may need treatment for both conditions 2