What is the best management approach for a patient experiencing a gastroesophageal reflux (GER) crisis, possibly with a history of erosive esophagitis?

Management of GER Crisis

For a patient experiencing a gastroesophageal reflux crisis, particularly with erosive esophagitis, immediately initiate twice-daily PPI therapy (e.g., omeprazole 20 mg, lansoprazole 30 mg, or rabeprazole 20 mg) taken 30-60 minutes before breakfast and dinner, combined with urgent lifestyle modifications including head-of-bed elevation and weight loss if BMI ≥25 kg/m². 1

Immediate Pharmacologic Management

First-Line Acid Suppression

• Start with twice-daily PPI dosing immediately rather than escalating from once-daily, as crisis presentations warrant aggressive initial therapy 1
• Administer 30-60 minutes before breakfast and dinner for optimal acid suppression during postprandial periods 1, 2
• All PPIs (omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole) have similar efficacy, with healing rates of 80-95% at 4-8 weeks 3, 4
• PPIs are vastly superior to H2-receptor antagonists, which develop tachyphylaxis within 6 weeks and should not be used as primary therapy 2, 3

Adjunctive Breakthrough Therapy

• Add alginate-containing antacids for immediate symptom relief between PPI doses, particularly for postprandial symptoms 1, 5
• These agents neutralize the "acid pocket" that forms after meals and provide rapid symptomatic relief 5

Urgent Lifestyle Interventions

Mandatory Modifications

• Elevate the head of bed by 6-8 inches (not just pillows) for all patients, especially those with nocturnal symptoms or regurgitation 1, 5
• Weight loss is mandatory for all patients with BMI ≥25 kg/m², as this has the strongest evidence (Grade B) for reducing GERD symptoms 5
• Avoid eating within 3 hours of bedtime to minimize nocturnal acid exposure 1

Diagnostic Evaluation During Crisis

When to Perform Urgent Endoscopy

• Perform urgent upper endoscopy if alarm symptoms are present: dysphagia, bleeding, anemia, weight loss, or recurrent vomiting 1
• In a crisis presentation with suspected severe erosive esophagitis, endoscopy helps grade disease severity using the Los Angeles classification and identify complications 1
• Endoscopy yields clinically actionable findings in >50% of patients with dysphagia, including strictures, severe erosions, or malignancy 1

Follow-Up Endoscopy Requirements

• For severe erosive esophagitis (Los Angeles grade C or D), perform follow-up endoscopy after 8 weeks of PPI therapy to confirm healing and rule out Barrett's esophagus, which develops in approximately 6% of these patients 1
• If initial endoscopy shows Los Angeles grade B or worse erosive disease, this confirms the diagnosis and justifies long-term PPI therapy 1

Treatment Duration and Escalation

Initial Treatment Course

• Continue twice-daily PPI therapy for 4-8 weeks as the initial healing phase 1, 6
• Most patients with erosive esophagitis heal within 4 weeks, though some require up to 8 weeks 6, 3
• If symptoms persist after 4 weeks on twice-daily therapy, extend treatment to 8 weeks before considering alternative diagnoses 2, 6

Refractory Cases

• If symptoms remain uncontrolled after 8-12 weeks of optimized twice-daily PPI therapy, perform objective testing rather than empirically increasing doses further 1, 5
• Consider 96-hour wireless pH monitoring OFF PPI therapy to objectively confirm GERD diagnosis and phenotype the disease 1
• Newer potassium-competitive acid blockers (P-CABs like vonoprazan) may be reserved for patients who fail twice-daily PPI therapy, though cost-effectiveness favors PPIs as first-line 2, 7

Long-Term Maintenance Strategy

For Confirmed Erosive Esophagitis

• Patients with healed erosive esophagitis have an 80% recurrence rate at one year without maintenance therapy 3
• Continue long-term daily PPI therapy at the lowest effective dose that maintains symptom control 1
• Do NOT use less-than-daily dosing in patients who had erosive esophagitis, as H2-receptor antagonists and intermittent PPI dosing are no better than placebo for preventing relapse 1, 5, 3
• Reassess the appropriateness and dosing within 12 months after initiation 1

Dose Optimization

• Once symptoms are controlled and healing is confirmed, attempt to taper to the lowest effective dose (often once-daily) 1
• Some patients may require continued twice-daily dosing for maintenance, particularly those with severe baseline disease 1

Phenotype-Specific Adjunctive Therapies

For Specific Symptom Patterns

• Baclofen for regurgitation-predominant or belch-predominant symptoms, though limited by CNS and GI side effects 1
• Prokinetics only if coexistent gastroparesis is documented; they have no proven role in GERD alone 1
• Neuromodulators and/or cognitive behavioral therapy for patients with esophageal hypervigilance or reflux hypersensitivity 1

Critical Pitfalls to Avoid

• Never use H2-receptor antagonists as primary therapy for erosive esophagitis, as they are significantly inferior to PPIs and develop tachyphylaxis 2, 3
• Do not perform routine endoscopic surveillance in patients with chronic GERD symptoms without erosive disease, as this has not been shown to diminish cancer risk 1
• Do not continue empiric PPI therapy indefinitely without objective confirmation of GERD if the diagnosis was never proven endoscopically or with pH monitoring 1
• Emphasize PPI safety to patients, as unfounded concerns about long-term risks often lead to premature discontinuation 1