What is the best treatment for reflux esophagitis?

Treatment of Reflux Esophagitis

Proton pump inhibitors (PPIs) are the best treatment for reflux esophagitis, with standard dosing of omeprazole 20mg or lansoprazole 30mg once daily taken 30-60 minutes before breakfast achieving healing rates of 80-95% at 8 weeks. 1, 2, 3

First-Line Pharmacologic Treatment

PPIs are superior to H2-receptor antagonists and placebo for both healing esophagitis and achieving symptomatic relief. 1, 2

• Start with omeprazole 20mg or lansoprazole 30mg once daily, taken 30-60 minutes before the first meal of the day to optimally suppress acid production 1, 2
• Allow 4 weeks to assess initial response before escalating therapy 1
• Healing rates with lansoprazole 30mg daily reach 82.5% at 4 weeks, 93% at 6 weeks, and 92.1% at 8 weeks, compared to ranitidine's 52%, 67.8%, and 69.9% respectively 3
• For documented erosive esophagitis on endoscopy, PPIs are the mandatory initial treatment choice 1, 2

Treatment Escalation for Persistent Symptoms

If symptoms persist after 4 weeks of standard once-daily PPI therapy, escalate to twice-daily dosing (one dose before breakfast and one before dinner). 1, 2

• Twice-daily PPI dosing provides superior acid suppression compared to once-daily dosing 4
• For extraesophageal manifestations of reflux esophagitis (chronic cough, laryngitis), more intensive therapy with twice-daily PPI for 8-12 weeks minimum is required 1, 4
• Consider endoscopy after failed empiric therapy to assess severity of esophagitis or identify alternative pathology 1

Essential Lifestyle Modifications

Weight loss is the most evidence-based lifestyle modification and should be recommended to all overweight or obese patients with reflux esophagitis. 1, 4, 2

• Elevate the head of the bed by 6-8 inches for patients with nighttime symptoms or regurgitation, as this improves esophageal pH profiles 1, 4, 2
• Avoid lying down for 2-3 hours after meals, which reduces esophageal acid exposure by 30-50% 1, 4, 2
• Limit dietary fat to ≤45g per 24 hours and avoid trigger foods including coffee, tea, chocolate, mints, citrus products, tomatoes, and alcohol 1, 4
• Complete smoking cessation rather than reduction provides maximal benefit 4

Maintenance Therapy

After achieving symptom control and esophageal healing, titrate to the lowest effective PPI dose that maintains remission. 1, 2

• Lansoprazole 15mg daily maintains endoscopic remission in 79% of patients at 12 months, compared to 24% with placebo 3
• For confirmed erosive esophagitis or Barrett's esophagus, long-term PPI therapy is generally required, and benefits outweigh risks 2
• Periodically reassess the need for continued PPI therapy to minimize potential long-term risks including impaired cognition, bacterial gastroenteritis, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease 5, 1

Management of Refractory Cases

For patients failing standard twice-daily PPI therapy, implement intensive medical therapy including strict antireflux diet, prokinetic agents, and address comorbid conditions. 1, 4

• Maintain twice-daily PPI and add prokinetic therapy (though avoid metoclopramide due to unfavorable risk-benefit profile including tardive dyskinesia risk) 1, 2
• Implement strict antireflux diet: ≤45g fat/day, eliminate all trigger foods (coffee, tea, soda, chocolate, mints, citrus, alcohol) 1, 4
• Address comorbid conditions that worsen GERD such as sleep apnea 1, 4
• Allow minimum 3 months of intensive medical therapy before considering surgical referral 1, 4

Surgical Consideration

Antireflux surgery (laparoscopic fundoplication) should be considered for patients with objectively documented GERD who fail maximum medical therapy for at least 3 months and have significant quality of life impairment. 4, 2

• Surgery shows improvement or cure in 85-86% of properly selected patients who have failed intensive medical therapy 1, 4
• Objective documentation requires endoscopy and/or 24-hour esophageal pH monitoring demonstrating persistent GERD before proceeding to surgery 4, 2

Common Pitfalls to Avoid

• Do not use empiric PPI therapy without proper timing: PPIs must be taken 30-60 minutes before meals for optimal efficacy 1, 2
• Do not broadly apply all lifestyle modifications to every patient: Focus on evidence-based modifications (weight loss, head of bed elevation, avoiding lying down after meals) rather than unproven restrictions 2
• Do not add nocturnal H2RA to twice-daily PPI as standard practice, as there is no evidence of improved efficacy with this combination 2
• Do not use metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile 1, 2