Reflux Oesophagitis

Mucosal injury of the distal oesophagus (erosions, ulcers) caused by repeated reflux of gastric acid, pepsin and bile; it is the erosive form of gastro-oesophageal reflux disease.

• Weekly reflux symptoms affect about 10 to 20% of adults in Western countries (and 5 to 10% in much of Africa and Asia); about 30% of those with symptoms have erosive disease on endoscopy.
• Endoscopic severity: grade A (one or more breaks of 5 mm or less), grade B (a break of more than 5 mm, not continuous between the tops of mucosal folds), grade C (breaks continuous between folds involving less than 75% of the circumference), grade D (breaks involving 75% or more of the circumference).
• Causes: transient lower oesophageal sphincter relaxation, hiatus hernia, obesity, pregnancy, delayed gastric emptying, smoking, alcohol, large fatty meals, scleroderma, drugs (calcium channel blockers, nitrates, anticholinergics, theophylline, benzodiazepines), and H. pylori eradication in some.
• Mechanism: failure of the antireflux barrier (sphincter, diaphragm crura, angle of His) with prolonged oesophageal acid exposure and impaired clearance and mucosal resistance.

Heartburn (retrosternal burning after meals or on lying), regurgitation, water brash, belching, epigastric pain, nocturnal symptoms.

• Atypical: chronic cough, hoarseness, throat clearing, asthma, dental erosions, noncardiac chest pain.
• Alarm features: dysphagia, odynophagia, vomiting, weight loss, anaemia, gastrointestinal bleeding, age over 55 years with new symptoms.
• Differential diagnosis: coronary disease, peptic ulcer, functional heartburn, eosinophilic oesophagitis, achalasia, infective or pill oesophagitis, gastroparesis, biliary disease, oesophageal cancer.
• Complications: peptic stricture (about 5 to 10% of severe untreated), bleeding, Barrett oesophagus (about 10% of chronic reflux), adenocarcinoma, aspiration pneumonia, laryngeal injury, dental erosion.

Typical symptoms with a good response to a proton pump inhibitor course support diagnosis; endoscopy is not needed for uncomplicated heartburn under 55 years of age with no alarm features.

• Upper endoscopy for alarm features, age over 55 years, symptoms that persist after 8 weeks of treatment, long-standing symptoms (more than 5 years, male, over 50 years) to screen for Barrett oesophagus, or before surgery; biopsies for Barrett oesophagus, stricture, ulcer or eosinophilic oesophagitis.
• Ambulatory pH or pH-impedance monitoring (off proton pump inhibitor for 7 days, or on treatment for refractory symptoms): acid exposure time of more than 6% is abnormal, less than 4% normal, 4 to 6% borderline.
• High-resolution manometry before antireflux surgery (exclude achalasia and poor motility).
• Barium swallow or CT for hiatus hernia, stricture or other disease; H. pylori testing in dyspepsia.

Lifestyle: lose weight (5 to 10% of body weight), raise the head of the bed by 15 to 20 cm, avoid meals within 3 hours of lying down, small meals, avoid triggers (fatty foods, alcohol, coffee, chocolate, carbonated drinks, peppermint), stop smoking, review drugs.

• Acid suppression:
  • Omeprazole 20 to 40 mg once daily (esomeprazole 40 mg, lansoprazole 30 mg, pantoprazole 40 mg or rabeprazole 20 mg daily) for 8 weeks; healing in about 80 to 90% (grades C and D need 40 mg daily and may need 40 mg twice daily).
  • Vonoprazan 20 mg daily for 8 weeks (10 mg daily for maintenance) is an alternative in places where available, with better healing in severe erosive disease.
  • Famotidine 20 mg twice daily for mild or nocturnal symptoms (10 mg twice daily when creatinine clearance is under 50 mL/min).
  • Alginate-antacid 10 to 20 mL after meals and at bedtime for breakthrough symptoms.
• Maintenance: omeprazole 10 to 20 mg daily (or on demand dosing for grade A and B), indefinite for grade C and D, stricture or Barrett oesophagus; reassess the need yearly and step down to the lowest effective dose.
• Refractory symptoms (not responding to 8 weeks of twice daily proton pump inhibitor): confirm adherence (30 minutes before meals), exclude non-acid reflux and eosinophilic oesophagitis, pH-impedance monitoring, baclofen 5 to 10 mg three times daily (evidence limited, drowsiness), metoclopramide 10 mg three times daily before meals (no more than 5 days at a time because of neurological effects), or neuromodulators (amitriptyline 10 to 25 mg at night) for functional heartburn.
• Antireflux surgery (laparoscopic fundoplication with hiatal repair) or magnetic sphincter augmentation for proven reflux with persistent symptoms or regurgitation despite treatment, large hiatus hernia, or when drugs are not tolerated; symptom control in about 85 to 90% at 5 years; side effects are dysphagia, bloating and inability to belch; endoscopic transoral fundoplication in selected patients. In obesity, gastric bypass is the preferred operation.
• Peptic stricture: balloon or bougie dilatation to 15 to 18 mm (repeat at 1 to 2 week intervals), with omeprazole 40 mg daily.
• Complications: Barrett oesophagus (surveillance endoscopy with biopsies every 3 to 5 years for a short segment and every 2 to 3 years for a long segment), ulcer bleeding (omeprazole 80 mg IV bolus then 8 mg/hour for 72 hours and endoscopic therapy).
• Special groups: children and infants (thickened feeds, head elevation, omeprazole 1 mg/kg once daily, maximum 40 mg, for 8 weeks; alginate 1 sachet after feeds; surgery for neurological impairment with aspiration); pregnancy (lifestyle, alginate-antacid, famotidine 20 mg twice daily, omeprazole 20 mg daily if needed); elderly (pill review, check calcium and B12 on long-term acid suppression); renal impairment (famotidine reduction, avoid magnesium and aluminium antacids); obesity (weight loss, bariatric surgery); systemic sclerosis (high-dose omeprazole 40 mg twice daily, prokinetics).
• Red flags: dysphagia, weight loss, haematemesis or melaena, iron deficiency anaemia, persistent vomiting, chest pain with exertion, age over 55 years with new onset.
• Follow-up: review at 8 weeks; repeat endoscopy at 8 weeks for grade C or D disease to confirm healing and exclude Barrett oesophagus (biopsies of any columnar-lined segment); yearly review of the dose and need for the proton pump inhibitor, with checks of magnesium, B12 and bone health after more than 1 year of treatment in high-risk patients.