What is the diagnosis and treatment for esophagitis?

From the Guidelines

Esophagitis should be treated based on its underlying cause, with proton pump inhibitors (PPIs) being effective in inducing histological and clinical remission in patients with eosinophilic oesophagitis, as recommended by the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition 1.

Treatment Approaches

• For reflux esophagitis, lifestyle modifications including weight loss, avoiding meals within 3 hours of bedtime, and elevating the head of the bed are recommended.
• Medications include PPIs like omeprazole 20-40mg daily or pantoprazole 40mg daily for 4-8 weeks, often with an initial 2-week course of H2 blockers like famotidine 20mg twice daily.
• For infectious esophagitis, treatment targets the specific pathogen: fluconazole 200mg on day 1 followed by 100mg daily for 14-21 days for Candida; acyclovir 400mg five times daily for 14-21 days for herpes; and ganciclovir for cytomegalovirus.
• Eosinophilic esophagitis responds to dietary elimination therapy and topical steroids like fluticasone 440-880mcg twice daily or budesonide 1mg twice daily for 8 weeks.
• Pill-induced esophagitis requires discontinuing the offending medication and taking medications with plenty of water while upright.

Maintenance Therapy

• Long-term use of PPIs for the treatment of patients with esophagitis once they have proven clinically effective is strongly recommended, with the dose titrated down to the lowest effective dose based on symptom control 1.
• For patients with erosive disease at baseline or severe GERD suspected, continuing PPI indefinitely and considering anti-reflux intervention for chronic maintenance is recommended 1.

Diagnostic Evaluation

• Endoscopy is often necessary for diagnosis and to rule out more serious conditions.
• Esophageal physiologic testing (HRM, Esophagram) may be considered to assess pre-intervention diagnoses candidacy and for alternative considerations.
• A precision approach based on pattern of reflux on pH-impedance monitoring, integrity of anti-reflux barrier, obesity, and/or psychological considerations may be used to guide treatment 1.

From the FDA Drug Label

Omeprazole delayed-release capsules are indicated for the short-term treatment (4 to 8 weeks) of EE due to acid-mediated GERD that has been diagnosed by endoscopy in patients 2 years of age and older If a patient does not respond to 8 weeks of treatment, an additional 4 weeks of treatment may be given. Omeprazole delayed-release capsules are indicated for the maintenance healing of EE due to acid-mediated GERD in patients 2 years of age and older.

Esophagitis Treatment: Omeprazole delayed-release capsules are used for the short-term treatment (4 to 8 weeks) of erosive esophagitis (EE) due to acid-mediated gastroesophageal reflux disease (GERD) in patients 2 years of age and older. If needed, an additional 4 weeks of treatment may be given. The capsules are also used for the maintenance healing of EE due to acid-mediated GERD in patients 2 years of age and older 2 2.

From the Research

Definition and Treatment of Esophagitis

• Esophagitis is characterized by excessive esophageal acid exposure, and treatment aims to reduce this exposure to within the normal range 3.
• The first-line drug for treating reflux esophagitis is a standard-dose proton-pump inhibitor (PPI), with a response rate of 90-100% in mild cases and 80-85% in severe cases 3.

Treatment Options for Refractory Reflux Esophagitis

• For PPI-resistant reflux esophagitis, modification of lifestyle with PPI therapy, switching to another PPI, or changing the administration method may be effective 3.
• Vonoprazan, a potassium-competitive acid blocker, has shown rapid and potent acid-suppressive effects and may be effective for reflux esophagitis, although clinical data are still insufficient 3, 4.
• Once-daily omeprazole/sodium bicarbonate has been shown to heal severe refractory reflux esophagitis with morning or nighttime dosing 5.

Comparative Efficacy of Vonoprazan and PPIs

• A systematic review found that vonoprazan had a higher healing effect than rabeprazole (20 mg) but not higher than other PPIs for GERD patients 4.
• Subgroup analysis indicated that vonoprazan is more effective than most PPIs for patients with severe erosive esophagitis 4.

Diagnosis and Management of Eosinophilic Esophagitis

• A trial of proton pump inhibitor (PPI) therapy is a mandatory diagnostic first step for suspected eosinophilic esophagitis (EoE) 6.
• Topical steroids followed by endoscopic dilation are recommended for symptomatic narrow caliber esophagus/strictures, while either topical steroids or dietary therapy are good short-term options for mucosal inflammation 6.

Clinical Guidelines for GERD

• The American College of Gastroenterology (ACG) has published clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD), including pharmacologic, lifestyle, surgical, and endoscopic management 7.
• The guidelines provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, with a focus on the safety of long-term PPI use and the potential for surgical and endoscopic interventions 7.