What is the diagnosis for a patient with Los Angeles (LA) grade A esophagitis, an irregular gastroesophageal (GE) junction, and pathology results showing gastric and esophageal mucosa with mild reflux changes, negative for intestinal metaplasia, and no eosinophils?

From the Guidelines

LA grade A esophagitis with an irregular gastroesophageal (GE) junction represents mild erosive reflux disease, despite the pathology showing only mild reflux changes without intestinal metaplasia or eosinophilic infiltration, and should be treated with a proton pump inhibitor (PPI) and lifestyle modifications. According to the 2022 clinical practice update by Yadlapati et al. 1, patients with esophageal symptoms and unproven GERD, such as those with LA grade A esophagitis, should undergo an initial 4-8 week trial of PPI therapy.

Treatment Approach

• The recommended initial treatment is a PPI such as omeprazole 20mg or pantoprazole 40mg once daily, taken 30 minutes before breakfast for 8 weeks, as this has been shown to effectively control symptoms in patients with mild erosive reflux disease 1.
• Lifestyle modifications are essential and include weight loss if overweight, avoiding meals within 3 hours of bedtime, elevating the head of the bed by 6-8 inches, and avoiding trigger foods (spicy, fatty, acidic foods, chocolate, coffee, and alcohol).
• After the initial 8-week course, patients with symptom resolution can attempt step-down therapy to an H2-blocker like famotidine 20mg twice daily or continue with on-demand PPI therapy, as suggested by the guidelines 1.

Follow-Up and Monitoring

• The irregular GE junction noted on endoscopy warrants follow-up endoscopy in 1-3 years to monitor for any progression, even though the current biopsy is negative for intestinal metaplasia (Barrett's esophagus) 1.
• The discrepancy between the endoscopic appearance and histology is common, as inflammation can cause visual changes that may not be reflected in random biopsies, highlighting the importance of regular monitoring and follow-up endoscopies.

From the Research

LA Grade A Esophagitis with Irregular GE Junction

• The condition described as LA grade A esophagitis with an irregular GE junction, but with pathology showing gastric and esophageal mucosa with mild reflux changes, negative for intestinal metaplasia, and no intrepid eosinophils, suggests a case of gastroesophageal reflux disease (GERD) without evidence of eosinophilic esophagitis or Barrett's esophagus 2.
• The absence of intestinal metaplasia is significant, as it is a precursor lesion for dysplasia and cancer in the context of GERD 2.
• The presence of mild reflux changes and an irregular GE junction is consistent with chronic inflammation and potential damage from acid reflux, but the lack of intestinal metaplasia and eosinophils indicates a less severe condition than those described in studies of eosinophilic esophagitis 3, 4, 5.

Differential Diagnosis

• Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated esophageal disorder characterized by eosinophil-predominant inflammation, which is not present in this case 3, 4, 5.
• Barrett's esophagus, a condition in which the esophageal lining changes to resemble the intestinal lining, is also not present, as indicated by the negative result for intestinal metaplasia 6, 2.

Pathology and Clinical Implications

• The pathology results showing gastric and esophageal mucosa with mild reflux changes are consistent with a diagnosis of GERD, which can cause symptoms such as heartburn, dysphagia, and chest pain 2.
• The absence of intestinal metaplasia and eosinophils suggests a lower risk of progression to more severe conditions, such as dysplasia or cancer, but ongoing monitoring and management of GERD symptoms are still necessary 2.