Management of gastro-oesophageal reflux in adults when endoscopic findings are known
For adults who have had an upper gastrointestinal endoscopy (see Indications for upper gastrointestinal endoscopy in patients with symptoms suspected to be due to gastro-oesophageal reflux for indications), therapy depends on the severity of both mucosal disease and symptoms. The aims of therapy are to control symptoms and reduce the risk of complications.
Previously untreated patients with no endoscopic evidence of erosive oesophagitis, or those with milder forms of erosive disease (Los Angeles grades A and B1), should be managed according to the severity of symptoms—see management of mild intermittent symptoms or management of frequent or severe symptoms.
Severe mucosal disease (Los Angeles grades C and D1) occurs in less than 10% of all patients with GORD, and only about 25% of patients with erosive disease. These patients should be managed in consultation with a gastroenterologist. In patients with severe mucosal disease, a higher degree of acid suppression leads to more rapid and complete healing compared with standard-dose therapy. Therefore, if endoscopy reveals severe erosive disease or ulceration in a previously untreated patient, high-dose PPI therapy is appropriate. Suitable high-dose PPI regimens are2:
1esomeprazole 20 mg orally, twice daily, half to one hour before a meal esomeprazole esomeprazole esomeprazole
OR
1lansoprazole 30 mg orally, twice daily, half to one hour before a meal lansoprazole lansoprazole lansoprazole
OR
1omeprazole 20 mg orally, twice daily, half to one hour before a meal omeprazole omeprazole omeprazole
OR
1pantoprazole 40 mg orally, twice daily, half to one hour before a meal pantoprazole pantoprazole pantoprazole
OR
1rabeprazole 20 mg orally, twice daily, half to one hour before a meal. rabeprazole rabeprazole rabeprazole
Following the healing course (usually 8 weeks), patients with severe mucosal disease should be stepped down to a PPI dose that provides adequate symptom control—do not stop PPI therapy completely, particularly in patients with previous peptic strictures or scleroderma affecting the oesophagus, because symptomatic and endoscopic relapse is highly likely.