What is the first‑line treatment for an adult with mild gastritis and gastro‑oesophageal reflux disease that has caused oesophagitis?

Treatment for Mild Gastritis and GERD with Esophagitis

Start with a proton pump inhibitor (PPI) at standard dose—omeprazole 20 mg or pantoprazole 40 mg—taken 30–60 minutes before breakfast daily for 4–8 weeks, combined with weight loss if overweight and head-of-bed elevation for nighttime symptoms. 1, 2

First-Line Pharmacologic Therapy

PPIs are the most effective first-line treatment for GERD with esophagitis, demonstrating superior healing rates and symptom relief compared to H2-receptor antagonists and placebo. 3, 2, 4

• Omeprazole 20 mg once daily taken 30–60 minutes before breakfast is the standard initial dose 1, 2
• Pantoprazole 40 mg once daily is therapeutically equivalent and preferred if the patient requires clopidogrel (due to minimal drug interaction) 1
• Continue initial therapy for 4–8 weeks to allow adequate time for esophagitis healing and symptom resolution 2, 5

Evidence for PPI Efficacy in Erosive Esophagitis

In controlled trials of pantoprazole for erosive esophagitis, healing rates at 8 weeks were 92.6% with 40 mg daily versus 39.7% with placebo, and 82.9% versus 41.4% with nizatidine 150 mg twice daily. 5 PPIs heal erosive esophagitis significantly faster than H2-receptor antagonists and provide more complete symptomatic relief. 3, 4

Essential Lifestyle Modifications

Weight loss is the single most effective lifestyle intervention (Grade B evidence) for patients with BMI ≥25 kg/m², improving both esophageal pH profiles and symptoms. 2, 6

• Elevate the head of the bed by 6–8 inches for patients with nighttime symptoms or regurgitation, as this improves esophageal pH profiles (evidence B) 2, 6
• Avoid lying down for 2–3 hours after meals to reduce esophageal acid exposure 3, 2
• Identify and eliminate individual trigger foods through detailed dietary history rather than imposing broad restrictions—common triggers include coffee, chocolate, alcohol, spicy foods, citrus, and high-fat meals 2

Important caveat: Tobacco and alcohol cessation, while generally recommended for health, have not been shown to improve GERD symptoms or esophageal pH profiles in controlled studies (evidence B). 6 However, weight loss and positional therapy have proven efficacy. 6

Treatment Escalation Algorithm

Step 1: Assess Response at 4 Weeks

• If symptoms persist despite adherence to once-daily PPI, escalate to twice-daily dosing (one dose before breakfast, one before dinner) for an additional 4–8 weeks 3, 2
• Twice-daily PPI provides more complete acid suppression when standard dosing is insufficient 2, 7

Step 2: Endoscopic Evaluation at 8–12 Weeks

• Perform upper endoscopy after 8–12 weeks of optimized twice-daily PPI therapy if symptoms remain uncontrolled, to assess for:
  • Severity of erosive esophagitis (Los Angeles grade)
  • Barrett's esophagus
  • Strictures
  • Eosinophilic esophagitis
  • Alternative diagnoses 2, 8

Maintenance Therapy

Long-term PPI therapy is indicated for patients with healed erosive esophagitis to prevent relapse, as discontinuation results in high recurrence rates. 3

• Titrate to the lowest effective dose that maintains symptom control after initial healing 3, 2
• Daily maintenance therapy is superior to on-demand therapy for patients with documented erosive esophagitis, as on-demand regimens result in high recurrence rates of erosive disease 3, 7
• Controlled studies support maintenance therapy for up to 12 months in adults 5

Important Distinction

On-demand PPI therapy may be reasonable for patients with non-erosive reflux disease (symptom control is the primary objective), but patients with confirmed erosive esophagitis require continuous daily therapy to maintain mucosal healing. 3, 7

Management of Concurrent Gastritis

For patients with both gastritis and GERD with esophagitis, the same PPI regimen addresses both conditions, as acid suppression promotes healing of gastric and esophageal mucosa. 1, 4

• Test for and eradicate Helicobacter pylori if present, particularly in patients with gastritis 3
• Higher-potency PPIs (esomeprazole 20–40 mg or rabeprazole 20 mg twice daily) are recommended when H. pylori eradication is indicated 1

Therapies to Avoid

• Do not use metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile, including risk of tardive dyskinesia (Grade D recommendation) 2
• Do not add nocturnal H2-receptor antagonists to twice-daily PPI therapy, as this combination provides no additional benefit and tachyphylaxis develops within 6 weeks 2

Common Pitfalls

• Do not continue empiric PPI therapy indefinitely without objective testing if symptoms persist beyond 8–12 weeks of optimized treatment 2
• Do not assume normal endoscopy rules out GERD in patients with persistent symptoms—consider 24-hour pH monitoring off PPI to confirm diagnosis 2, 8
• Do not use less-than-daily PPI dosing as maintenance therapy in patients who previously had erosive esophagitis, as this results in high recurrence rates 3

Pediatric Considerations

For pediatric patients ages 5–16 years with erosive esophagitis, efficacy data are extrapolated from adult studies, as the pathophysiology is considered the same. 5 Safety beyond 8 weeks in pediatric patients has not been established. 5