What is the initial management for a patient with esophageal stricture?

From the Guidelines

The initial management for a patient with esophageal stricture typically involves endoscopic dilation, which is the first-line treatment to relieve dysphagia symptoms. This procedure uses either bougie dilators (Savary-Gilliard) or through-the-scope balloon dilators to gradually stretch the narrowed esophageal segment.

Key Considerations

• Dilation sessions are usually performed in intervals, starting conservatively and potentially increasing the dilator size in subsequent sessions based on patient response.
• Alongside dilation, proton pump inhibitors (PPIs) such as omeprazole 20-40 mg daily or esomeprazole 20-40 mg daily should be prescribed, especially if the stricture is related to gastroesophageal reflux disease (GERD) 1.
• The use of wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques for all patients is recommended to enhance safety 1.
• For refractory or recurrent strictures, additional options include steroid injections (triamcinolone 40 mg/mL) into the stricture during endoscopy, temporary stent placement, or incisional therapy.
• The underlying cause of the stricture (such as GERD, eosinophilic esophagitis, radiation injury, or caustic ingestion) should be identified and treated appropriately to prevent recurrence.
• Patients should be advised to eat slowly, chew thoroughly, and avoid foods that are difficult to swallow to minimize symptoms while undergoing treatment.

Timing and Frequency of Dilation Sessions

• The timing of subsequent dilatation sessions may depend on the degree of success of initial dilatation and the patient's response to the procedure 1.
• Perform weekly or two-weekly dilatation sessions until easy passage of a ≥15 mm dilator is achieved along with symptomatic improvement 1.

Contraindications and Cautions

• Oesophageal dilatation should not be performed in patients with active or incompletely healed oesophageal perforation 1.
• Patients with a recent, healed perforation; recent upper gastrointestinal surgery; pharyngeal or cervical deformity; or bleeding disorders should be considered for dilatation after careful consideration of the benefits, risks, and alternatives of the procedure 1.

From the Research

Initial Management for Esophageal Stricture

The initial management for a patient with esophageal stricture involves several key considerations:

• Esophageal dilation is the treatment of choice for most patients with esophageal dysphagia, including those with esophageal stricture 2
• Multiple forms of esophageal dilators are available, including mechanical dilators and balloon dilators, with mechanical dilators being the major form used 2
• The use of proton pump inhibitors (PPIs) is important in the management of esophageal stricture, particularly in cases where the stricture is associated with gastroesophageal reflux disease (GERD) 3, 4, 5

Role of Proton Pump Inhibitors

• PPIs have been shown to decrease the need for dilatation of peptic oesophageal strictures 5
• The use of PPIs has been associated with a decrease in the incidence of esophageal stricture formation in patients with reconstructed esophageal atresia 6
• PPIs are also used as prophylaxis against anastomotic stricture in patients with reconstructed esophageal atresia, although the optimal duration of PPI prophylaxis is not well established 6

Esophageal Dilation

• Esophageal dilation is a safe and effective procedure for the management of esophageal stricture, with a low risk of complications 2
• The choice of dilator (mechanical or balloon) depends on the individual patient and the specific characteristics of the stricture 2
• Predilation barium studies are not always necessary, but may be useful in certain cases, such as when the endoscope is unable to pass the stricture and the stricture length and angulation are unknown 2