What is the management approach for a patient with reflux esophagitis?

Management of Reflux Esophagitis

Initial Pharmacologic Treatment

Proton pump inhibitors (PPIs) are the first-line treatment for reflux esophagitis, with a standard dose of 30 mg lansoprazole (or equivalent) taken 30-60 minutes before breakfast for 4-8 weeks, achieving healing rates of 81-95% compared to 33-53% with placebo. 1, 2

PPI Dosing Strategy

• Start with single-dose PPI therapy (e.g., omeprazole 20 mg, lansoprazole 30 mg, or esomeprazole 40 mg) taken 30-60 minutes before the first meal of the day 1, 3
• If inadequate response after 4 weeks, escalate to twice-daily dosing (one dose before breakfast, one before dinner) rather than switching agents initially 1, 3
• For confirmed erosive esophagitis (Los Angeles grade B or higher), PPIs are superior to H2-receptor antagonists, with lansoprazole 30 mg achieving 93% healing at 6 weeks versus 68% with ranitidine 2
• After symptom resolution, taper to the lowest effective dose that maintains control 1, 3

Concurrent Lifestyle Modifications

Weight loss is the single most effective lifestyle intervention for GERD, with the strongest evidence base (Grade B), and should be recommended for all patients with BMI ≥25 kg/m². 1, 3

Evidence-Based Lifestyle Changes

• Elevate the head of the bed by 6-8 inches (15-20 cm) for patients with nocturnal symptoms or regurgitation when recumbent 1, 3
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 1, 3
• Identify and avoid individual trigger foods through detailed dietary history rather than applying blanket dietary restrictions 3
• Limit dietary fat intake to ≤45 grams per day as part of an antireflux diet 3
• Smoking cessation and alcohol limitation should be advised 3

Assessment and Treatment Response

Response Evaluation at 4-8 Weeks

• For patients with symptom resolution: taper PPI to the lowest effective dose or convert to on-demand therapy if no erosive disease was present at baseline 1
• For patients with partial or no response: verify compliance, increase to twice-daily PPI dosing, or switch to a more potent acid suppressive agent 1
• For patients requiring long-term PPI therapy (>12 months): offer endoscopy with prolonged wireless pH monitoring off PPI to establish appropriate use of chronic therapy 1

Diagnostic Testing Indications

Upper endoscopy is warranted for PPI non-responders, presence of alarm symptoms (dysphagia, weight loss, GI bleeding), isolated extra-esophageal symptoms, or patients meeting criteria for Barrett's esophagus screening. 1

Endoscopic Evaluation Components

• Grade erosive esophagitis according to Los Angeles classification (grades A-D) 1
• Assess diaphragmatic hiatus using Hill grade of flap valve 1
• Measure axial hiatus hernia length if present 1
• Inspect for Barrett's esophagus with Prague classification and biopsy when present 1

pH Monitoring Strategy

• In the absence of Los Angeles grade B or greater erosive disease or long-segment Barrett's esophagus (≥3 cm), perform prolonged wireless pH monitoring off medication (96-hour preferred if available) 1
• Patients with acid exposure time (AET) ≥6.0% on 2 or more days confirm GERD diagnosis 1
• Patients with physiologic acid exposure likely have functional esophageal disorder and may not require long-term PPI therapy 1

Maintenance Therapy

Patients with confirmed erosive esophagitis or Barrett's esophagus require indefinite PPI therapy, with lansoprazole 15-30 mg daily maintaining remission in 79-90% of patients at 12 months versus 13-24% with placebo. 1, 2

Long-Term Management Strategy

• For non-erosive disease with symptom control: wean to lowest effective dose or on-demand therapy with H2 blockers/antacids 1
• For erosive disease (Los Angeles B-D) or Barrett's esophagus: continue PPI indefinitely as benefits outweigh risks 1, 3
• For severe GERD phenotype (AET >12%, Los Angeles C-D, bipositional reflux, or DeMeester score ≥50): requires continuous long-term PPI or consideration of anti-reflux procedures 1
• Periodically reassess appropriateness and dosing, but emphasize PPI safety to patients 1, 3

Adjunctive Pharmacotherapy

Adjunctive agents should be personalized to the GERD phenotype rather than used empirically. 1

• Alginate antacids for breakthrough symptoms 1
• Nighttime H2-receptor antagonists (e.g., famotidine) for nocturnal symptoms specifically 1
• Baclofen for regurgitation-predominant or belch-predominant symptoms 1
• Prokinetics only for coexistent gastroparesis 1
• Avoid metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile, including tardive dyskinesia risk 3

Refractory GERD Management

Pre-Surgical Evaluation

• Perform esophageal physiologic testing (high-resolution manometry, esophagram) to assess candidacy and exclude alternative diagnoses 1
• Confirm pathologic GERD with objective testing, exclude achalasia, and assess esophageal peristaltic function 1
• Consider 24-hour pH-impedance monitoring on PPI to determine mechanism of persistent symptoms if adequate expertise exists for interpretation 1
• Evaluate gastric emptying if symptoms suggest gastroparesis 1

Surgical and Endoscopic Options

In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, with transoral incisionless fundoplication as an effective endoscopic option in carefully selected patients without hiatal hernia. 1

• Partial fundoplication is preferred in patients with known esophageal hypomotility or impaired peristaltic reserve when postoperative dysphagia is a concern 1
• Magnetic sphincter augmentation is often combined with crural repair in the setting of known hiatal hernia 1
• In obese patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention, while sleeve gastrectomy has potential to worsen GERD 1

Neuromodulation for Functional Disorders

• For patients without erosive disease on endoscopy and physiologic acid exposure (functional heartburn or reflux hypersensitivity): provide pharmacologic neuromodulation and/or referral for cognitive behavioral therapy, gut-directed hypnotherapy, diaphragmatic breathing, and relaxation strategies 1
• PPI therapy can be titrated off as tolerated in these patients 1

Common Pitfalls to Avoid

• Do not broadly recommend all lifestyle modifications to every patient—focus on weight loss (if overweight/obese) and head of bed elevation (if nocturnal symptoms), as evidence does not support blanket restrictions 3
• Do not add nocturnal H2RA to twice-daily PPI as standard practice, as there is no evidence of improved efficacy with this combination 3
• Do not use doses higher than standard PPI dosing without first optimizing timing (30-60 minutes before meals) and ensuring twice-daily dosing 3
• Do not continue empiric PPI therapy beyond 12 months without objective testing to confirm GERD diagnosis 1

Shared Decision-Making

• Develop a care plan with explanation of potential risks and benefits of therapy and long-term management, including possible de-escalation, in a shared decision-making model 1
• Provide standardized educational material on GERD mechanisms, weight management, lifestyle behaviors, relaxation strategies, and brain-gut axis relationship 1
• Emphasize safety of PPIs for GERD treatment to address patient concerns 1