A false sense of security; symptom control does not predict healing of oesophagitis on proton pump inhibitors

Abstract

Sirs, The study by Labenz et al. attempted to determine the factors associated with resolution of heartburn in patients with reflux oesophagitis treated with proton pump inhibitor.1 Certainly, effective control of heartburn symptoms is crucial in treating patients with reflux oesophagitis; however, it is not the only goal. We suggest that treatment of the symptoms is but one part of the paradigm of treating reflux oesophagitis; the other therapeutic goals should include healing the oesophagitis, maintaining remission, prevention of complications and improvement in quality of life.2 Our study agreed with the findings of Labenz et al. that greater age was associated with a greater likelihood of heartburn resolution during proton pump inhibitor therapy. However, our study did not find any association between Helicobacter pylori status, male gender and symptoms resolution. Labenz J. et al. conclude that the results of their study should help physicians categorize reflux oesophagitis patients as likely to be ‘treatment responsive’ or ‘treatment refractory’; we feel this is worrisome on two grounds. First, our study found that symptom resolution on proton pump inhibition does not predict healing of oesophagitis. In fact, whilst 75.8% of our study patients had complete resolution of their symptoms, only 48% had complete healing of the oesophagitis at endoscopy after 8 weeks of proton pump inhibition.2 Secondly, it remains uncertain as to the long-term sequelae of mild oesophagitis; some studies have found very low rates of gastro-oesophageal reflux-related complications3, 4 including strictures and Barrett’s oesophagus, whereas other studies have suggested a higher rate of GERD-related complications.5, 6 Treatment of symptoms is critical in the management of patients with reflux oesophagitis, but until there is unequivocal evidence that mild oesophagitis has little by the way of long-term sequelae, it is important not to be lulled into a false sense of security in patients who are proton pump inhibitor ‘treatment responsive’ symptom wise, as resolution of symptoms does not necessarily mean the resolution of oesophagitis. Declaration of personal and funding interests: None.