Bacterial Esophagitis When Acid-Suppression Therapy Fails to Control Nocturnal Acid Breakthrough and GERD Symptoms

Clinical Scenario

This protocol addresses bacterial esophagitis in patients who have already undergone optimised pharmacological acid suppression and have not achieved adequate symptom control. Specifically, it applies when the goals of the prior treatment line — reduction of nocturnal acid breakthrough and resolution of GERD symptoms — were not met.

Prior Treatment — Failure Criteria for Escalation

The preceding line involved optimising or switching acid-suppression agents, including PPIs (with dosage adjustments), H2 receptor antagonists, and potassium-competitive acid blockers (P-CABs). Escalation to this protocol is triggered when that regimen fails to achieve reduction of nocturnal acid breakthrough and GERD symptoms.

Next-Line Approach (Partial Overview)

For patients refractory to pharmacotherapy, or who need to discontinue long-term acid-suppression medications, the evidence supports moving to a procedural intervention. The approach involves a surgical or endoscopic technique directed at the lower esophageal region. The full protocol specifies the options, selection criteria, and clinical decision points.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.14218/JTG.2025.00006

Surgery and endoscopic therapy should be considered for refractory patients or those on long-term treatment with PPIs or P-CABs who need to discontinue the medications.

Laparoscopic fundoplication can be useful for selected patients with EE who are refractory to therapy or unable to tolerate or comply with long-term pharmacotherapy.

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