A 56-year-old obese man (BMI 34) with a 12-year history of nightly heartburn refractory to standard-dose proton pump inhibitor undergoes upper endoscopy. He reports nocturnal cough, hoarseness, and intermittent dysphagia. Endoscopy reveals a 4 cm hiatal hernia and multiple longitudinal mucosal breaks extending from the squamocolumnar junction. The structure marked **A** in the diagram—confluent mucosal breaks bridging between the tops of mucosal folds but involving less than 75% of esophageal circumference—is identified. According to the Los Angeles Classification, what is the most appropriate next step in management?

Question

Accepted Answer

B. High-dose proton pump inhibitor twice daily for 8–12 weeks, followed by maintenance therapy and surveillance endoscopy after healing. ## Why High-dose PPI twice daily for 8–12 weeks is right

Los Angeles Grade C erosive esophagitis—defined by confluent mucosal breaks bridging between tops of mucosal folds but involving <75% of circumference—requires high-dose proton pump inhibitor therapy, typically twice-daily dosing (e.g., omeprazole 40 mg BID, esomeprazole 40 mg BID) for 8–12 weeks to achieve healing. After healing, maintenance PPI is usually required given the high relapse rate of Grade C disease. Surveillance endoscopy for Barrett esophagus should be deferred until after healing because active severe esophagitis can mask or mimic dysplasia, and the prevalence of Barrett rises with severity of erosive esophagitis (Sleisenger and Fordtran 11e Ch 46; AGA Clinical Practice Update on GERD 2022).

## Why each distractor is wrong

- **Standard-dose PPI once daily indefinitely**: Standard-dose therapy is insufficient for Grade C esophagitis; this patient has already failed standard-dose PPI. High-dose twice-daily dosing is mandated by the severity of the lesion and the clinical anchor.
- **Immediate antireflux surgery (Nissen fundoplication)**: Surgery is indicated for PPI failure, intolerance, large hiatal hernia, or volume regurgitation—not as first-line for Grade C disease. Medical therapy must be optimized first; surgery is reserved for refractory cases after adequate high-dose PPI trial.
- **Potassium-competitive acid blocker monotherapy for 4 weeks with no follow-up**: Although vonoprazan achieves faster acid suppression and is approved for severe erosive esophagitis, 4 weeks is insufficient duration (standard is 8–12 weeks), and omitting follow-up endoscopy contradicts the need for surveillance after healing to detect Barrett esophagus.

**High-Yield:** LA Grade C = confluent breaks bridging folds but <75% circumference → high-dose PPI BID × 8–12 weeks + maintenance + post-healing surveillance for Barrett.

[Schatzki LA classification Gastroenterology 1999; AGA Clinical Practice Update on GERD 2022; Sleisenger and Fordtran 11e Ch 46]

Answer

A. Standard-dose proton pump inhibitor once daily continued indefinitely without repeat endoscopy

Answer

C. Immediate antireflux surgery (Nissen fundoplication) given the severity of erosive esophagitis

Answer

D. Potassium-competitive acid blocker monotherapy for 4 weeks with no follow-up endoscopy

Explanation

Why High-dose PPI twice daily for 8–12 weeks is right

Why each distractor is wrong

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