What is the best initial evaluation and treatment approach for an older adult with a thickened esophageal lining and a history of Gastroesophageal Reflux Disease (GERD)?

Thickened Esophageal Lining in an Older Adult with GERD

In an older adult with a thickened esophageal lining and known GERD, proceed immediately to upper endoscopy with biopsy to exclude Barrett's esophagus, eosinophilic esophagitis, malignancy, and fungal infection, while simultaneously initiating or optimizing twice-daily PPI therapy. 1

Immediate Diagnostic Evaluation

Upper Endoscopy with Comprehensive Assessment

• Perform endoscopy to evaluate for erosive esophagitis using the Los Angeles classification, assess for Barrett's esophagus using the Prague classification with biopsy, measure hiatal hernia length, and grade the diaphragmatic hiatus. 1
• Obtain biopsies from areas of thickening to exclude eosinophilic esophagitis (≥15 eosinophils per high-power field) and to identify fungal forms, as both conditions can present with esophageal wall thickening. 1, 2
• Distal esophageal wall thickening ≥5 mm on CT imaging has moderate association with reflux esophagitis (sensitivity 56%, specificity 88%), but endoscopy remains the gold standard for diagnosis. 1

Critical Differential Diagnoses to Exclude

• Barrett's esophagus: A precancerous condition requiring surveillance that develops from chronic GERD exposure 1, 3
• Eosinophilic esophagitis: Presents with dysphagia and esophageal wall thickening, particularly in the submucosa, and is unresponsive to acid suppression 1, 4
• Candidal esophagitis: Especially if the patient has recent antibiotic use, immunosuppression, or chronic PPI therapy—biopsy showing fungal forms requires fluconazole 200-400 mg daily for 14-21 days 2
• Esophageal adenocarcinoma: Barrett's esophagus can progress to malignancy, making early detection critical 3

Immediate Medical Management

Aggressive Acid Suppression

• Initiate or escalate to twice-daily PPI therapy (e.g., omeprazole 20-40 mg twice daily before meals) immediately, as thickened esophageal lining suggests severe or chronic GERD requiring maximal acid suppression. 1, 5, 6
• Continue PPI therapy for at least 8 weeks for healing of erosive esophagitis, with potential extension to 12 weeks if needed. 1, 5

Mandatory Lifestyle Modifications

• Elevate the head of bed by 6-8 inches for all sleep periods to prevent nocturnal reflux. 7
• Avoid recumbency for 3 hours after meals to minimize reflux episodes. 7
• Implement weight loss if BMI >25, as excessive body weight is a modifiable risk factor for GERD progression. 7, 8
• Eliminate trigger foods including fatty/fried foods, chocolate, coffee, carbonated beverages, alcohol, citrus, tomatoes, and spicy foods. 8

Subsequent Management Based on Endoscopic Findings

If Erosive Esophagitis or Barrett's Esophagus is Confirmed

• Do not wean PPI therapy in patients with documented erosive esophagitis (Los Angeles Grade B or higher) or Barrett's esophagus—these patients require indefinite maintenance therapy. 7
• Establish surveillance protocols for Barrett's esophagus according to Prague classification findings. 1

If Eosinophilic Esophagitis is Diagnosed

• Recognize that symptoms will be unresponsive to acid suppression alone, as EoE is an immune-mediated condition. 1
• Distal esophageal wall thickness, particularly submucosal thickening, correlates with dysphagia severity in EoE but not GERD. 4

If Fungal Infection is Identified

• Treat with fluconazole 200-400 mg daily for 14-21 days when biopsy demonstrates fungal forms invading tissue. 2
• Consider prophylactic nystatin if multiple risk factors persist (ongoing immunosuppression, recurrent antibiotics, severe GERD). 2

Long-Term Management Strategy

Objective Testing for Chronic Therapy

• After 12 months of continuous PPI therapy, perform prolonged wireless pH monitoring (96-hour preferred) OFF PPI to confirm pathologic GERD and justify continued long-term therapy. 7
• If pH monitoring shows physiologic acid exposure (<4% acid exposure time), discontinue PPI and consider neuromodulators or behavioral interventions for functional esophageal disorder. 7

Refractory Symptoms Despite Optimal Medical Therapy

• Perform 24-hour pH-impedance monitoring ON PPI to determine mechanism (persistent acid reflux vs. non-acid reflux vs. esophageal hypersensitivity). 1, 7
• Consider esophageal manometry to exclude achalasia or esophageal dysmotility and assess candidacy for anti-reflux procedures. 1
• Evaluate for surgical intervention (laparoscopic fundoplication or magnetic sphincter augmentation) in patients with confirmed severe GERD and preserved esophageal peristalsis who remain symptomatic despite optimized medical therapy. 1, 7

Critical Pitfalls to Avoid

• Never assume thickened esophageal lining is benign reflux esophagitis without endoscopic confirmation and biopsy—Barrett's esophagus and malignancy must be excluded. 1
• Do not continue empiric PPI therapy beyond 12 months without objective confirmation of GERD diagnosis through endoscopy and pH monitoring. 7
• Do not overlook eosinophilic esophagitis in patients with persistent dysphagia despite PPI therapy—this requires biopsy for diagnosis. 1
• Recognize that PPI therapy carries risks including bone fractures, chronic kidney disease, and Clostridium difficile infection with long-term use, making objective confirmation of GERD essential before committing to indefinite therapy. 5, 3