What is the management of reflux esophagitis?

Management of Reflux Esophagitis

Proton pump inhibitors (PPIs) at 30 mg daily (e.g., lansoprazole) are the first-line treatment for reflux esophagitis, taken 30-60 minutes before the first meal of the day, with healing rates of 81-95% at 4-8 weeks. 1, 2

Initial Pharmacologic Management

• Start with a PPI (lansoprazole 30 mg, omeprazole 20 mg equivalent) once daily, taken 30-60 minutes before breakfast for patients with documented erosive esophagitis 1, 3, 2
• PPIs are superior to H2-receptor antagonists (H2RAs) for both healing erosive esophagitis and achieving symptomatic relief 1, 4, 5
• For typical GERD symptoms without alarm features (dysphagia, weight loss, GI bleeding), empiric PPI therapy for 4-8 weeks is appropriate without initial endoscopy 1, 3
• Lansoprazole 30 mg daily achieved 81.3% healing at 4 weeks and 95.4% healing at 8 weeks in erosive esophagitis, compared to only 32.8% and 52.5% with placebo 2

Lifestyle Modifications (Essential Adjuncts to PPI Therapy)

Weight loss is the single most effective lifestyle intervention and should be recommended for all overweight or obese patients (BMI ≥25 kg/m²) 1, 6, 3

Dietary and Behavioral Changes:

• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 7, 1, 6, 3
• Avoid late evening meals before bedtime 7, 1
• Identify and avoid individual trigger foods (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes, fatty foods) based on consistent symptom provocation rather than blanket restrictions 7, 1, 6
• Limit fat intake to ≤45g per day as part of an antireflux diet 1

Positional Therapy:

• Elevate the head of the bed by 6-8 inches for patients with nighttime symptoms or regurgitation 7, 1, 6, 3
• Sleep in the left lateral decubitus position to reduce nocturnal reflux episodes 7, 6

Treatment Escalation for Persistent Symptoms

If symptoms persist after 4 weeks of standard once-daily PPI therapy, escalate to twice-daily PPI dosing (one dose before breakfast, one before dinner) 7, 1, 6, 3

• Twice-daily PPI provides superior gastric acid suppression and is more effective for refractory symptoms 7
• For extraesophageal symptoms (chronic cough, laryngitis, asthma), twice-daily PPI for 8-12 weeks minimum is required, though response rates are lower than for typical GERD 7, 1
• Consider endoscopy after failed empiric therapy to assess for erosive disease, Barrett's esophagus, or alternative diagnoses 1, 3

Maintenance Therapy

After achieving symptom control and healing, continue PPI therapy indefinitely for patients with documented erosive esophagitis 1, 6

• Lansoprazole 15-30 mg daily maintained 79-90% of patients in endoscopic remission at 12 months, compared to only 13-24% with placebo 2
• Titrate to the lowest effective PPI dose for patients without erosive esophagitis at baseline 1, 6, 3
• Periodically reassess the need for continued PPI therapy to minimize potential long-term risks (vitamin B12 deficiency, hypomagnesemia, chronic kidney disease, hip fractures) 1, 3

Management of Refractory Disease

If symptoms persist despite twice-daily PPI therapy:

• Optimize PPI timing and compliance before escalating further 3
• Consider 24-hour esophageal pH monitoring off PPI to confirm GERD diagnosis 3
• Address comorbid conditions that worsen GERD, such as obstructive sleep apnea 7, 1
• Adding H2RA at bedtime to twice-daily PPI is not recommended due to lack of efficacy evidence and development of tachyphylaxis 1, 6
• Avoid metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile, including risk of tardive dyskinesia 1

Surgical Considerations

Antireflux surgery (laparoscopic fundoplication) may be considered for patients with objectively documented GERD who fail maximal medical therapy for at least 3 months 1, 3

• Surgery shows improvement or cure in 85-86% of properly selected patients 1
• Patients must have objective documentation of persistent GERD and significant quality of life impairment 1

Common Pitfalls to Avoid

• Do not add nocturnal H2RA to twice-daily PPI as standard practice—no evidence supports improved efficacy 1
• Do not use higher than standard PPI doses without first optimizing timing and ensuring twice-daily dosing 1
• Do not broadly recommend all lifestyle modifications to every patient—focus on weight loss, head of bed elevation, and avoiding recumbency after meals, which have the strongest evidence 1
• Do not expect the same response rates for extraesophageal symptoms (chronic cough, laryngitis) as for typical GERD—meta-analyses show PPIs provide no clear benefit over placebo for these symptoms 7