What is the management plan for a 54-year-old male patient with a history of GERD (Gastroesophageal Reflux Disease), who underwent an EGD (Esophagogastroduodenoscopy) procedure that revealed a benign stricture in the gastroesophageal junction, longitudinal furrows in the esophagus, and erythema and nodularity in the stomach body?

Management Plan for GERD with Esophageal Stricture, Longitudinal Furrows, and Gastric Inflammation

This patient requires long-term daily PPI therapy at the lowest effective dose, avoidance of NSAIDs, aggressive lifestyle modifications including weight management, and close follow-up pending biopsy results to rule out eosinophilic esophagitis and evaluate for Barrett's esophagus. 1

Immediate Post-Procedure Management

PPI Therapy Optimization

• Continue daily PPI therapy indefinitely given the presence of a peptic stricture at the gastroesophageal junction, which represents an acid-related complication requiring long-term maintenance therapy 2, 3
• The dose should be periodically reevaluated to ensure the lowest effective dose is used, but daily dosing (not less than daily) is mandatory for patients with previous strictures 1
• If symptoms recur or persist, escalation to twice-daily PPI dosing is appropriate before considering the patient a treatment failure 1, 2

NSAID Avoidance

• Strict avoidance of NSAIDs is critical as documented in the discharge plan, since NSAIDs can exacerbate esophageal injury and stricture formation 2
• This patient should remain on PPI therapy if any future NSAID use becomes necessary for other conditions 3

Critical Pending Evaluations

Biopsy Results: Rule Out Eosinophilic Esophagitis (EoE)

The endoscopic findings of diffuse longitudinal furrows in the middle and lower esophagus are highly concerning for eosinophilic esophagitis, which can coexist with GERD 4, 5

Key diagnostic criteria to evaluate:

• Esophageal biopsies showing ≥15 eosinophils per high-power field would confirm EoE 6
• The combination of longitudinal furrows, stricture formation, and male gender significantly increases the likelihood of EoE 5
• If EoE is confirmed, this fundamentally changes management as PPI therapy alone may be insufficient, and additional therapies (topical corticosteroids, dietary elimination, or biologic agents) would be required 6

Stricture Risk Assessment

This patient's stricture characteristics should be evaluated against predictive factors for refractory benign esophageal strictures (RBES):

• Stricture length ≥2 cm, diameter ≤7 mm, and proximal/diffuse location predict higher risk of refractoriness 7
• The report describes a 15 mm diameter stricture that was 2 mm long at the GE junction—this appears to be a low-risk stricture based on these criteria 7
• However, if EoE is confirmed, the risk of recurrent stricture and food impaction increases substantially, particularly in males with furrows and rings 5

Barrett's Esophagus Surveillance

• The gastric body biopsies showing erythema and nodularity require histologic evaluation for intestinal metaplasia 1
• If Barrett's esophagus is identified, long-term daily PPI therapy is mandatory regardless of symptom control 3
• The presence of a stricture with healing may unmask Barrett's esophagus in approximately 6% of cases with severe esophagitis 1

Lifestyle Modifications

Aggressive lifestyle interventions are essential adjuncts to pharmacotherapy 1:

• Weight loss (current BMI 28.74 indicates overweight status) through caloric restriction and exercise 1
• Elevation of head of bed by 6-8 inches 2
• Avoiding meals within 3 hours of bedtime 2
• Limiting alcohol, caffeine, chocolate, and acidic foods 1

Laboratory Evaluation

Obtain hemogram and iron indices as recommended to assess for:

• Chronic blood loss from erosive disease 2
• Iron deficiency anemia which may indicate more severe or chronic esophageal inflammation 2

Follow-Up Strategy

Short-Term (2-4 Weeks)

• Review all biopsy results (esophageal, gastric, and duodenal) with the patient 2
• If EoE is confirmed, initiate appropriate therapy (topical budesonide or fluticasone, dietary elimination trial, or referral to allergist) 6
• Assess symptom response to current PPI regimen 1

Medium-Term (3-6 Months)

• Repeat EGD may be indicated if:
  • EoE is confirmed to assess treatment response 6
  • Barrett's esophagus is identified to establish surveillance intervals 3
  • Symptoms recur despite optimal medical therapy 1
  • Dysphagia persists or worsens, suggesting stricture recurrence 7

Long-Term Management

• Annual reassessment of PPI necessity if no Barrett's esophagus or severe erosive disease is found 1
• However, given the stricture history, lifelong daily PPI is likely required 1
• Periodic monitoring for PPI-related complications is not routinely recommended (no need for routine calcium, B12, magnesium supplementation or bone density screening) 3

Common Pitfalls to Avoid

Do not attempt PPI weaning or on-demand therapy in this patient given the stricture—this is a Grade D recommendation (recommend against) for patients with previous erosive complications 1

Do not dismiss the longitudinal furrows as simple GERD findings—these are pathognomonic for EoE and require histologic confirmation 4, 5

Do not perform routine surveillance endoscopy for disease progression unless Barrett's esophagus is confirmed or symptoms recur, as this has not been shown to reduce cancer risk 1

Ensure the patient understands that stricture dilation is a temporizing measure—without adequate acid suppression and treatment of any underlying EoE, strictures commonly recur 7, 6

Adjunctive Pharmacotherapy Considerations

If breakthrough symptoms occur despite optimized PPI therapy 1:

• Alginate antacids for post-prandial or nighttime symptoms 1
• Nighttime H2-receptor antagonist (though limited by tachyphylaxis) 1
• Baclofen if regurgitation or belching predominates 1
• Neuromodulators or behavioral therapy if functional overlay is suspected after objective testing 1