A 45-year-old male presents with a complaint of “heartburn.” He has experienced symptoms of substernal burning three to five times per week over the last 18 months. He has acid regurgitation one to two times per month. He denies dysphagia, weight loss, GI bleeding, nausea or vomiting. A recent CBC and CMP were normal. He has tried over-the-counter antacids and H-2 blockers twice daily, with minimal relief of symptoms. He has no chronic disease and is not on chronic medications other than those described above. A recent EGD revealed LA grade A esophagitis.

Which of the following treatment regimens is the next step for this patient with LA grade A esophagitis?

A) H-2 blockers, orally, twice daily
B) H-2 blockers, orally, twice daily, with antacids as needed
C) Proton pump inhibitor (PPI), orally, twice daily, 30-60 minutes before meals
D) PPI, orally, daily, 30-60 minutes before a meal

The correct answer is D, daily PPI, 30-60 minutes before a meal.

Practice Pearls

Pathophysiology:

• Gastroesophageal reflux disease (GERD) is a condition in which reflux of gastric contents into the esophagus results in symptoms and/or complications.¹
• GERD is objectively defined by the presence of characteristic mucosal injury seen at endoscopy (erosive esophagitis) and/or abnormal esophageal acid exposure on a reflux monitoring study.
• Esophagitis results from cytokine-triggered inflammation rather than a direct chemical effect of prolonged exposure to acid, pepsin and bile on the esophageal epithelium.²
• Gastroesophageal junction incompetence includes^1,2 transient lower esophageal sphincter relaxations, a hypotensive lower esophageal sphincter (LES), and anatomic disruption of the gastroesophageal junction, often associated with a hiatal hernia.
• Impaired esophageal emptying may contribute to GERD through ineffective esophageal motility and retrograde flow associated with hiatal hernias.² Additionally, diminished salivary excretion may contribute to GERD.²
• Additional etiologic factors contributing to GERD include obesity, diet (fatty foods, chocolate), medications (calcium channel blockers) and pregnancy (estrogen and progesterone reduce LES tone).²

Diagnosis

Symptoms:

• There is no gold standard for the diagnosis of GERD. ¹ Diagnosis is based on symptom presentation, an endoscopic evaluation and reflux monitoring.¹
• Classic GERD symptoms include heartburn or regurgitation.¹
• Extraesophageal reflux symptoms include hoarseness, chronic cough, laryngitis, pharyngitis and pulmonary fibrosis.¹

Endoscopy:

When to pursue endoscopic evaluation:

• Patients with classic GERD symptoms who do not respond to an eight-week trial of empiric PPI therapy or whose symptoms return after discontinuation of treatment.^{1, 4}
• Alarm symptoms (dysphagia, odynophagia, unintentional weight loss, unexplained iron deficiency anemia, GI bleeding). ^{1, 4}
• Chest pain (after heart disease is ruled out). ^{1, 4}
• Multiple risk factors for Barrett’s esophagus (BE) (smoking, chronic GERD, obesity, male, White, >50 years of age). ^{1, 4}
• New onset of GERD in individuals older than 60 years of age.^{1, 4}
• Stop PPIs two to four weeks before EGD to avoid missing eosinophilic esophagitis and to accurately evaluate the severity of esophagitis/degree of erosion.^{1, 4}
• Endoscopic findings for the diagnosis of GERD: LA grade B or higher, peptic stricture or BE segment > 3 cm.^{1, 4}
• If endoscopic evaluation does not show any evidence of GERD with clinical suspicion of GERD, pH monitoring should be considered. ⁴

Reflux Monitoring:

• Esophageal pH monitoring (Bravo, catheter-based or combined impedance-pH monitoring) performed off PPI therapy for at least seven days for diagnosis of GERD.^{1, 4}
• Ideally, wireless pH testing over 96 hours or pH impedance testing over 24 hours.^{1, 4}
• Interpretation of results of wireless pH monitoring for two days or more: ⁴
• Acid exposure time (AET) greater than 6.0 percent: Highly indicative of GERD.
• AET of less than 4 percent: Excludes GERD.
• AET between 4 and 6 percent: Inconclusive studies.
• Reflux monitoring is not needed for the diagnosis of GERD in patients with endoscopic evidence of LA grade C or D esophagitis.^{1, 4}
• If the patient experiences extraesophageal reflux symptoms (hoarseness, chronic cough, laryngitis, pharyngitis and pulmonary fibrosis) without classic heartburn and regurgitation, they should undergo reflux testing before initiating PPI therapy.^{1, 4}

Management

Nonpharmacological/Lifestyle Modifications:^{1, 4}

• Weight loss in individuals with overweight and/or obesity.
• Avoid meals within two to three hours before bedtime.
• Cessation and avoidance of tobacco products.
• Identify and avoid/minimize consumption of trigger foods (citrus, spicy foods, tomato-based foods, chocolate, mint, caffeine, alcohol)
• Elevate the head of the bed to 45 degrees at nighttime.

Pharmacological Management for Erosive Esophagitis:

• PPIs are the first-line therapy for the treatment and maintenance of erosive esophagitis (EE).
• Omeprazole is a good starting option for treatment of EE.^{1, 4}
• Attempt to discontinue PPIs if classic GERD symptoms respond to the eight-week trial with LA grade A and B esophagitis.^{1, 4}
• Individuals with LA grade C or D esophagitis and those with anti-reflux surgery should continue maintenance PPI therapy at the lowest effective dose.^{1, 4}
• New therapies for the treatment of EE: potassium competitive acid blockers. Recent research shows that vonoprazan provides more potent inhibition of gastric acid than PPIs, which may lead to more effective healing of erosive esophagitis. They also do not require the dose to be taken in regards to meals, which may help with patient adherence.^{3, 4}

Authors

Sarah Enslin, PA-C, is a physician assistant at the University of Rochester Medical Center in Rochester, NY, with over 10 years of experience as a practicing PA in GI. Sarah serves on several national GI committees and is a member of the ASGE Practice Operations Committee.

Sarah Kosinski, APN-BC, is a family nurse practitioner for the division of gastroenterology, section of endobariatrics, at Rush University Medical Center in Chicago.

Joseph Vicari, MD, FASGE, joined Rockford Gastroenterology in 1997 and has served as managing partner. He previously served as chair of the ASGE Practice Operations Committee and currently serves as councilor on the ASGE Governing Board and co-chair of the ASGE APP Task Force.

References

1. Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117:27-56. doi: 10.14309/ajg.0000000000001538
2. Kahrilis PJ. Pathophysiology of reflux esophagitis. UpToDate. Updated March 7, 2024. https://www.uptodate.com
3. Laine L, DeVault K, Katz P, et al. Vonoprazan versus lansoprazole for healing and maintenance of healing of erosive esophagitis: A randomized trial. Gastroenterology. 2023;164:61-71. doi: 10.1053/j.gastro.2022.09.041
4. Pandolfino JE, Spechler SJ, Yadlapati R. Updates in the management of erosive esophagitis. J Fam Pract. 2023;72(8 Suppl):S1-S12. doi: 10.12788/jfp.0666