Hiatal hernia is the key factor determining the lansoprazole dosage required for effective intra-oesophageal acid suppression M. FRAZZONI*, E. DE MICHELI*, A. GRISENDI* & V. SAVARINO   *Divisione di Medicina Interna e Gastroenterologia, Ospedale S. Agostino, Modena, Italy;  Dipartimento di Medicina Interna e Specialita ` Mediche, Universita ` di Genova, Genova, Italy Accepted for publication 21 January 2002 INTRODUCTION Gastro-oesophageal reflux disease (GERD) encompasses a variety of symptoms, coupled with endoscopically visible mucosal lesions in less than one-half of cases, resulting from abnormal exposure of the oesophageal mucosa to refluxed gastric material. 1 In the presence of hiatal hernia, a spatial separation of the lower oeso- phageal sphincter from the crural diaphragm occurs with an attendant reduction in the efficacy of the physiological anti-reflux barrier; 2, 3 a further conse- quence is impaired oesophageal emptying with pro- longed acid clearance. 4, 5 In recent years, hiatal hernia has resurged to prominence in GERD pathogenesis, 6 but its possible effects on medical treatment have yet to be explored. Proton pump inhibitors are the mainstay of medical treatment in GERD owing to their high efficacy in reducing the acidity of the refluxate. 1 Indeed, main- taining pH levels above 4 is considered to be the critical factor for the healing of severe ulcerative oesophagitis, 7 for reducing re-dilatation rates in patients with peptic oesophageal strictures 8 and for preventing the develop- ment of dysplasia and oesophageal adenocarcinoma in patients with Barrett’s oesophagus. 9, 10 Complete proton pump inhibitor-induced eradication of heartburn and acid regurgitation in such patients with GERD SUMMARY Background: Effective intra-oesophageal acid suppres- sion can be achieved with lansoprazole. The daily dosage could be influenced by the presence of hiatal hernia. Aim: To assess the lansoprazole daily dosage required to normalize oesophageal acid exposure in patients with and without hiatal hernia. Methods: Fifty patients with complications or atypical manifestations of gastro-oesophageal reflux disease were given lansoprazole, 30 mg once daily. Three to four weeks after the start of treatment, patients underwent oesophageal pH monitoring while on ther- apy. If the results were still abnormal, the lansoprazole dosage was doubled and 24-h pH-metry was repeated 20–30 days thereafter. Results: A 30-mg daily dosage of lansoprazole normal- ized oesophageal acid exposure in 70% of cases, whilst a 60-mg daily dosage was necessary in the remainder: the two groups differed only in the presence of hiatal hernia (28% vs. 100%, respectively; P ¼ 0.000). Effective intra-oesophageal acid suppression was obtained in all 25 patients without hiatal hernia with the 30-mg daily dosage of lansoprazole. Conclusions: Hiatal hernia is the key factor determining the lansoprazole dosage required for effective intra- oesophageal acid suppression in complicated and atyp- ical gastro-oesophageal reflux disease. High efficacy of a 30-mg daily dosage of lansoprazole can be predicted in the absence of hiatal hernia. Ó 2002 Blackwell Science Ltd 881 Correspondence to: Dr M. Frazzoni, Divisione di Medicina Interna e Gastroenterologia, Ospedale S. Agostino, P.zza S. Agostino 228, 41100 Modena, Italy. E-mail: marziofrazzoni@hotmail.com Aliment Pharmacol Ther 2002; 16: 881–886.