What is the treatment for a lax Lower Esophageal Sphincter (LES) diagnosed through Gastrointestinal (GI) endoscopy?

Treatment for Lax Lower Esophageal Sphincter (LES)

Start with a 4-8 week trial of once-daily proton pump inhibitor (PPI) therapy, which is the first-line treatment for gastroesophageal reflux disease (GERD) caused by lax LES. 1

Initial Medical Management

First-Line PPI Therapy

• Begin with single-dose PPI therapy for 4-8 weeks for patients with typical reflux symptoms (heartburn, regurgitation) without alarm symptoms. 1
• If symptoms persist after initial trial, escalate to twice-daily PPI dosing or switch to a more potent acid suppressive agent. 1
• Once symptoms are controlled, taper PPI to the lowest effective dose. 1
• PPIs are safe for GERD treatment, and patients should be reassured about their safety profile. 1

Lifestyle and Educational Interventions

• Provide standardized education on GERD mechanisms, weight management, lifestyle modifications, dietary behaviors, and relaxation strategies. 1
• Weight loss is particularly important, as obesity increases intra-abdominal pressure and reduces LES pressure. 2

Diagnostic Workup for Persistent Symptoms

When to Perform Endoscopy

• Perform upper GI endoscopy if symptoms don't respond adequately to PPI trial or when alarm symptoms exist. 1
• Complete endoscopic evaluation should document: erosive esophagitis (Los Angeles classification), diaphragmatic hiatus assessment (Hill grade), axial hiatal hernia length, and Barrett's esophagus screening. 1, 3
• Underlying esophageal disorders are found in up to 25% of patients with reflux symptoms. 1

Additional Testing for Refractory Cases

• If long-term PPI therapy is planned, offer objective reflux testing (prolonged wireless pH monitoring off PPI, 96-hour preferred) to confirm GERD diagnosis. 1
• Perform high-resolution manometry to exclude achalasia and assess esophageal peristaltic function before considering invasive procedures. 1, 3
• Consider 24-hour pH-impedance monitoring on PPI to determine mechanism of persistent symptoms and confirm PPI-refractory GERD. 1, 4

Adjunctive Pharmacotherapy

Targeted Add-On Medications

• Alginate antacids for breakthrough symptoms. 1
• Nighttime H2 receptor antagonists for nocturnal symptoms. 1
• Baclofen for regurgitation-predominant or belch-predominant symptoms. 1
• Prokinetics only if concomitant gastroparesis is present. 1

Neuromodulation and Behavioral Therapy

• Provide pharmacologic neuromodulation (low-dose antidepressants) and/or referral for behavioral therapy (hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing) in patients with esophageal hypervigilance, reflux hypersensitivity, or functional heartburn. 1

Invasive Anti-Reflux Procedures

Patient Selection Criteria

Candidacy for invasive procedures requires: 1, 3

• Confirmatory evidence of pathologic GERD through objective testing
• Exclusion of achalasia
• Assessment of normal esophageal peristaltic function

Surgical Options

• Laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options for proven GERD. 1
• Partial fundoplication is preferred in patients with esophageal hypomotility or impaired peristaltic reserve to reduce postoperative dysphagia risk. 1
• Magnetic sphincter augmentation is often combined with crural repair when hiatal hernia is present. 1
• Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients. 1

Endoscopic Options

• Transoral incisionless fundoplication (TIF) is an effective endoscopic option in carefully selected patients with proven GERD, particularly those with regurgitation-predominant symptoms and absence of large hiatal hernia. 1, 3
• TIF can be combined with laparoscopic hiatal hernia repair in patients with minor crural defects. 1
• TIF has been successfully combined with laparoscopic sleeve gastrectomy in obese patients with GERD. 2

Important Caveats

Contraindications to Endoscopic Fundoplication

• Severe erosive esophagitis (Los Angeles grade C or D). 3
• Esophageal motility disorders or impaired peristaltic function. 3
• Barrett's esophagus or other GERD complications. 3

Long-Term Considerations

• Patients with severe GERD (large hiatal hernia, severely hypotensive LES) generally require long-term anti-reflux management. 1, 5
• Hiatal hernia and hypotensive LES are present in most patients with severe erosive disease or Barrett's esophagus. 5
• Relapse occurs in approximately 70% of patients within 6 months after stopping PPI therapy. 6
• Long-term durability beyond 1-2 years remains unclear for most endoscopic techniques. 3