What is the treatment for severe esophagitis?

Treatment of Severe Esophagitis

Patients with severe erosive esophagitis (Los Angeles Classification grade C or D) should be treated with proton pump inhibitors (PPIs) at standard doses—omeprazole 20 mg twice daily or lansoprazole 30 mg once daily—for 8 weeks, with endoscopic reassessment to confirm healing, and should remain on long-term maintenance PPI therapy to prevent complications including GI bleeding, stricture formation, and progression to Barrett's esophagus. 1

Initial Treatment Approach

PPI Therapy as First-Line Treatment

• Standard dosing for severe erosive esophagitis includes omeprazole 20 mg twice daily or lansoprazole 30 mg once daily for 8 weeks. 1, 2

• PPIs achieve healing rates of 80-95% in severe erosive esophagitis (LA grade C/D) by 8 weeks, significantly superior to H2-receptor antagonists. 2, 3

• Lansoprazole 30 mg daily healed 81-95% of erosive esophagitis cases by 4-8 weeks in controlled trials, with the 30 mg dose recommended over lower doses due to earlier healing in severe disease. 2

• PPIs are more effective than H2-receptor antagonists in both symptom relief and healing rates, with H2RAs developing tachyphylaxis within 6 weeks, limiting their utility. 1

Treatment Duration and Monitoring

• Treat for a minimum of 8 weeks before assessing response, as this represents the standard duration demonstrated in clinical trials. 1, 2

• Endoscopic reassessment with biopsy is mandatory after 8 weeks of therapy to document mucosal healing, as symptom improvement does not reliably correlate with histological healing. 1, 4

• For patients with LA grade C or D esophagitis, a repeat endoscopy after 8 weeks of twice-daily PPI therapy is essential to confirm healing and assess for underlying Barrett's esophagus, which may be present in 10-12% of cases. 1

Long-Term Management

Maintenance Therapy

• Patients with healed severe erosive esophagitis require indefinite maintenance PPI therapy, as 80% will experience recurrence within one year without continued treatment. 3, 5

• PPIs should generally not be discontinued in patients with a history of severe erosive esophagitis (LA grade C/D) or GERD-related complications unless benefits and harms are carefully weighed and discussed with the patient. 1

• H2-receptor antagonists are ineffective for maintenance therapy in severe erosive esophagitis, performing no better than placebo in preventing relapse. 3

Monitoring for Complications

• Severe erosive esophagitis can lead to life-threatening complications including GI bleeding, stricture formation, and progression to Barrett's esophagus with subsequent risk of esophageal adenocarcinoma. 1

• Patients who develop dysphagia during or after treatment require urgent evaluation, as persistent dysphagia may indicate failed healing (healing rates drop from 90% to 72% in patients with persistent dysphagia) or stricture formation. 6

Special Considerations

Refractory Cases

• For patients failing standard-dose PPI therapy, consider higher doses (lansoprazole 60 mg daily showed similar efficacy to 30 mg in trials) or twice-daily dosing before switching to alternative therapies. 2

• Ensure compliance and proper PPI administration (30-60 minutes before meals) before labeling as refractory disease. 1

Distinguishing from Other Esophagitis Types

• Eosinophilic esophagitis requires different management: while PPIs are first-line (omeprazole 20 mg twice daily for 8-12 weeks), topical steroids are second-line for PPI non-responders, and these patients should never have PPIs discontinued if they have responded. 1, 4

• Biopsy during initial endoscopy helps distinguish erosive GERD from eosinophilic esophagitis, infectious esophagitis, or pill esophagitis, which require different treatment approaches. 1, 7

Common Pitfalls to Avoid

• Do not discontinue PPIs in patients with documented severe erosive esophagitis (LA grade C/D) even if asymptomatic, as this places them at high risk for complications. 1

• Do not rely on symptom resolution alone to assess healing—endoscopic confirmation is essential, as 37% of patients with erosive esophagitis have dysphagia at baseline, and symptom improvement may occur without complete mucosal healing. 6

• Do not use H2-receptor antagonists as maintenance therapy in severe erosive esophagitis, as they are ineffective in preventing relapse. 3

• Avoid empiric treatment without endoscopic diagnosis in patients with alarm symptoms (dysphagia, weight loss, bleeding), as severe erosive esophagitis requires confirmation and assessment for complications. 1