From the Guidelines
Recommended Dose of PPI for Paraesophageal Hernia
The recommended dose of PPI for a patient with a paraesophageal hernia is single-dose PPI therapy, with the option to escalate to twice-a-day dosing if symptoms persist 1.
PPI Optimization
- Single-dose PPI therapy is considered safe and appropriate for patients with typical reflux symptoms and no alarm symptoms, with escalation to twice-a-day dosing or switching to a more potent acid suppressive agent if symptoms persist 1.
- Symptom response should prompt PPI titration to the lowest effective dose 1.
- Patients with severe GERD require indefinite long-term PPI therapy and/or an invasive anti-reflux procedure 1.
- For patients with erosive esophagitis, biopsy-proven Barrett’s esophagus, and/or peptic stricture, long-term PPI therapy is required, with a minimum of single-dose PPI therapy 1.
Special Considerations
- Patients with paraesophageal hernia may require long-term PPI therapy to manage symptoms and prevent complications 1.
- Objective reflux testing should be offered to establish a diagnosis of GERD and a long-term management plan when long-term PPI therapy is planned 1.
From the Research
Recommended Dose of PPI for Paraesophageal Hernia
- The recommended dose of PPI for a patient with a paraesophageal hernia is not directly stated in the provided studies.
- However, a study by 2 found that a standard dose of esomeprazole (40 mg daily) was not effective in normalizing esophageal pH in almost 50% of patients with hiatus hernia, and a double dose (40 mg twice daily) was required to achieve normalization.
- Another study by 3 found that 70% of patients remained or were restarted on PPI after their initial surgery, but the use of PPIs may delay proper workup to identify recurrent hiatal hernia.
- A study by 4 found that 30% of patients were using daily PPIs after laparoscopic Hill repair, but the dose was not specified.
- A study by 5 found that some patients with a herniated wrap after laparoscopic paraesophageal hernia repair complained of heartburn, which was controlled with a proton pump inhibitor, but the dose was not specified.
PPI Use in Hiatal Hernia Repair
- The use of PPIs after hiatal hernia repair is common, but it may mask patients who would benefit from revisional surgery 3.
- A study by 4 found that the use of PPIs did not affect the long-term durability and quality of life after laparoscopic Hill repair.
- Another study by 5 found that some patients with a herniated wrap after laparoscopic paraesophageal hernia repair were asymptomatic, while others complained of heartburn, which was controlled with a proton pump inhibitor.
Dosing Considerations
- The dose of PPI required for a patient with a paraesophageal hernia may depend on the severity of symptoms and the presence of other conditions such as gastroesophageal reflux disease (GERD) 2, 3.
- Further studies are needed to determine the optimal dose of PPI for patients with paraesophageal hernia.