What is the best management approach for an adult girl with severe esophageal strictures following unintentional corrosive ingestion?

From the Guidelines

The best next step for the adult girl with severe esophageal strictures following unintentional corrosive ingestion is to continue endoscopic dilatation, as this approach has been shown to be effective in managing esophageal strictures and improving patient outcomes 1. The management of esophageal strictures following corrosive ingestion involves a multidisciplinary approach, with endoscopic dilation therapy being the primary treatment option.

• Initial management should include endoscopic assessment to determine the extent and severity of strictures.
• Regular endoscopic dilations using bougie or balloon dilators should be performed, typically starting with smaller sizes (7-9 mm) and gradually increasing to 15-18 mm.
• Dilations should be performed every 1-2 weeks initially, then spaced out as symptoms improve.
• Proton pump inhibitors such as omeprazole 40 mg daily or esomeprazole 40 mg daily should be prescribed to reduce acid reflux that could worsen strictures.
• For refractory strictures, temporary stent placement (fully covered self-expandable metal stents left in place for 4-8 weeks) or intralesional steroid injections (triamcinolone acetonide 40 mg/ml) may be beneficial.
• Surgical intervention with esophageal reconstruction or replacement should be considered for strictures that fail endoscopic management. The use of endoscopic dilation has been supported by recent guidelines, including the UK guidelines on oesophageal dilatation in clinical practice 1, which recommend timely management of oesophageal strictures with dilatation to improve patient outcomes.
• The guidelines also suggest using wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques for all patients to enhance safety.
• Fluoroscopic guidance should be used to enhance safety during dilatation of strictures that are either high risk or cannot be passed endoscopically.
• Carbon dioxide insufflation instead of air should be used during endoscopy whenever possible to minimize luminal distension and postprocedural pain. Overall, continuing endoscopic dilatation is the most appropriate next step for the adult girl with severe esophageal strictures following unintentional corrosive ingestion, as it addresses both the mechanical obstruction through dilation and the inflammatory component through acid suppression and potentially steroids, while maintaining esophageal patency and function whenever possible 1.

From the Research

Management Approach for Corrosive Esophageal Strictures

The management of corrosive esophageal strictures typically involves a step-by-step approach, starting with endoscopic dilatation. The following options are considered:

• Endoscopic Dilatation: This is the primary treatment for most patients with benign oesophageal strictures, including those caused by corrosive ingestion 2, 3. The procedure involves using dilators to gradually widen the narrowed portion of the esophagus.
• Stent Placement: This may be considered for patients who have failed endoscopic dilatation or have complex strictures 4.
• Oesophageal Resection or Bypass: These surgical options are typically reserved for patients who have failed endoscopic and stent placement treatments 3.

Factors Affecting Outcome of Endoscopic Dilatation

Several factors can affect the outcome of endoscopic dilatation, including:

• Stricture length: Longer strictures may be more challenging to treat 3, 5.
• Stricture location: Strictures in the upper or lower third of the esophagus may be more difficult to treat 6.
• Underlying aetiology: The cause of the stricture, such as acid or alkali ingestion, may influence the outcome of treatment 6.

Next Steps for the Patient

Based on the information provided, the patient has been undergoing regular dilatation for 3 months with feeding jejunostomy. The next steps for the patient could be:

• Continue Endoscopic Dilatation: If the patient is responding well to dilatation, this treatment can be continued 2, 3.
• Consider Stent Placement: If the patient is not responding to dilatation or has complex strictures, stent placement may be considered 4.
• Surgical Options: If all else fails, oesophageal resection or bypass may be considered 3.

Given the patient's history and current treatment, the most appropriate next step would be to:

• Continue endoscopic dilatation, as this is the recommended primary therapy for corrosive esophageal strictures 2, 3.