According to guidelines, should a repeat endoscopy be performed after a standard course of proton‑pump inhibitor therapy for Los Angeles grade B erosive esophagitis in an otherwise typical adult?

Repeat Endoscopy for LA Grade B Esophagitis After PPI Therapy

No, repeat endoscopy is NOT recommended for Los Angeles grade B esophagitis after PPI therapy in typical cases. Guidelines explicitly reserve follow-up endoscopy only for severe erosive esophagitis (LA grades C and D), not for grade B disease 1.

Guideline-Based Recommendations

When Repeat Endoscopy IS Required

• LA Grade C or D esophagitis only: The AGA Clinical Practice Update (2022) clearly states that "a relook endoscopy is only needed for those with Los Angeles Grade C and D esophagitis" 1.
• Purpose of repeat endoscopy in severe disease: To document healing of esophagitis, assess for features of malignancy, and evaluate for underlying Barrett's esophagus, which may be present in 10-12% of patients with severe esophagitis 1.
• Timing: After 8 weeks of twice-daily PPI therapy 1.

When Repeat Endoscopy IS NOT Required

• LA Grade A or B esophagitis: The American College of Physicians (2012) states that patients with documented severe erosive esophagitis (grade B or worse) warrant follow-up endoscopy, but this recommendation specifically targets the more severe end of grade B disease in the context of Barrett's screening 1.
• The most recent AGA guidance (2022) clarifies this further by explicitly limiting repeat endoscopy to grades C and D only 1.

Clinical Algorithm for LA Grade B Esophagitis

Initial Management

1. Treat with PPI therapy: Standard once-daily dosing for 4-8 weeks initially 1.
2. Escalate if needed: Twice-daily PPI if once-daily therapy unsuccessful 1.
3. Optimize timing: PPIs should be taken 30-60 minutes before meals for optimal efficacy 1, 2.

Follow-Up Strategy

• Symptom-based management: If symptoms resolve, continue maintenance PPI at lowest effective dose 1.
• No routine repeat endoscopy: For uncomplicated LA grade B esophagitis without alarm symptoms 1.
• Taper to lowest effective dose: Once adequate response achieved 1.

Exceptions Requiring Repeat Endoscopy

Specific Clinical Scenarios

• Alarm symptoms present: Dysphagia, bleeding, anemia, weight loss, or recurrent vomiting warrant repeat endoscopy regardless of LA grade 1.
• Concern for dysplasia or malignancy: If concerning endoscopic findings noted at initial endoscopy, biopsy and repeat endoscopy after 8 weeks of twice-daily PPI is appropriate 1.
• Persistent symptoms despite adequate PPI therapy: Consider repeat endoscopy to evaluate for incomplete healing or alternative diagnoses 1.
• Documented stricture: Symptom-based repeat endoscopy with dilation may be required 1.

Evidence Supporting Conservative Approach

Real-World Outcomes

• Natural history is benign: Research demonstrates that the majority of patients with LA grade A or B esophagitis show healing at follow-up endoscopy regardless of continued PPI use 3.
• No progression to severe disease: Studies show no patients with grade B esophagitis progressed to more severe grades 3.
• Barrett's risk is low: The rate of Barrett's esophagus in LA grade A/B esophagitis is approximately 5%, compared to 14% in grade C (though this difference was not statistically significant in one study) 3.
• Grade A/B and absence of hiatal hernia predict healing: These are independent predictors of esophagitis healing on multivariate analysis 3.

Healing Rates Without Repeat Endoscopy

• High healing rates with PPI: Even in real-world settings, remission rates for grade B esophagitis with PPI therapy are substantial 4.
• Symptom resolution correlates with healing: Resolution of symptoms like dysphagia is associated with 90% healing rates across PPI treatments 5.

Common Pitfalls to Avoid

Over-Testing

• Unnecessary repeat endoscopy: Performing routine follow-up endoscopy for LA grade B esophagitis increases costs and procedural risks without clear benefit in typical cases 1.
• Confusing grade B with severe disease: Grade B is considered mild-to-moderate erosive esophagitis, not severe disease requiring mandatory follow-up 1, 3.

Under-Recognition of High-Risk Features

• Missing alarm symptoms: Persistent dysphagia despite PPI therapy may indicate failed healing and warrants repeat endoscopy 5.
• Ignoring large hiatal hernia: Presence of hiatal hernia is associated with lower healing rates and may warrant closer follow-up 3.
• Failing to document Barrett's screening: If initial endoscopy showed active inflammation preventing adequate Barrett's assessment, consider repeat endoscopy after healing in high-risk patients (men >50 years with chronic GERD symptoms) 1.

Special Considerations

Barrett's Esophagus Screening Context

• If Barrett's screening is the goal: The presence of erosive esophagitis may prevent detection of underlying Barrett's esophagus 6.
• Consider repeat endoscopy after healing: Approximately 12% of patients with healed erosive esophagitis are found to have Barrett's esophagus (mainly short-segment) on repeat endoscopy 6.
• This applies primarily to high-risk patients: Men older than 50 years with chronic GERD symptoms 1.

When Biopsies Were Obtained at Initial Endoscopy

• If dysplasia suspected: Repeat endoscopy after 8-12 weeks of twice-daily PPI is mandatory to confirm findings and exclude inflammation-related over-diagnosis 1.
• Active inflammation affects pathology: Surveillance biopsies should ideally not be performed in the presence of active inflammation (LA grades C and D specifically mentioned, but principle applies to obtaining accurate pathology) 1.