From the Guidelines
The initial management for patients with scleroderma and esophageal stricture involves a combination of proton pump inhibitors (PPIs) and endoscopic dilation, with PPIs such as omeprazole 40 mg twice daily or equivalent recommended to reduce acid reflux, as suggested by the EULAR recommendations for the treatment of systemic sclerosis 1.
Key Considerations
- High-dose PPIs should be started to reduce acid reflux, which can worsen strictures.
- Endoscopic dilation is typically performed for symptomatic strictures causing dysphagia, with the goal of achieving a luminal diameter of 15-18 mm.
- Patients should be maintained on long-term PPI therapy even after successful dilation to prevent recurrence.
- Lifestyle modifications are also important, including elevating the head of the bed 6-8 inches, avoiding meals 2-3 hours before bedtime, and eliminating trigger foods.
Additional Recommendations
- Prokinetic agents like metoclopramide 10 mg before meals may help improve esophageal clearance, though their efficacy is limited in scleroderma due to smooth muscle dysfunction, as noted in the EULAR guidelines 1.
- The use of prokinetic drugs should be considered for the treatment of symptomatic motility disturbances related to SSc, as recommended by the EULAR guidelines 1.
Endoscopic Dilation Technique
- Consider limiting the initial dilatation to 10–12 mm in diameter in cases of very narrow strictures not passable by the adult gastroscope, as suggested by the UK guidelines on oesophageal dilatation in clinical practice 1.
- Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques for all patients to enhance safety, with a strong recommendation based on moderate evidence 1.
From the Research
Initial Management for Scleroderma and Esophageal Stricture
The initial management for patients with scleroderma and esophageal stricture involves a combination of medical and surgical approaches.
- Medical therapy is necessary to prevent complications such as peptic stricture and Barrett's esophagus 2.
- Surgical options include esophageal dilation, antireflux procedures, and colon interposition 3, 4.
- Antireflux procedures, such as fundoplication, can provide control of reflux and dysphagia, but may ultimately fail over time 3.
- Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been shown to lead to less dysphagia and better control of GERD symptoms compared to fundoplication 5.
- Esophageal replacement should be considered as the initial step in treatment of strictures of the esophagus in patients with scleroderma 3.
Treatment Options
- Esophageal dilation can provide temporary relief of dysphagia symptoms, but may require repeated sessions 6.
- Incisional therapy, such as with a Mori's knife, can be effective in treating refractory benign esophageal strictures 6.
- Antireflux procedures, such as the Thal-Nissen procedure, can be effective in treating distal esophageal strictures associated with scleroderma 4.
Considerations
- Patients with scleroderma are at increased risk of complications such as peptic stricture and Barrett's esophagus due to gastroesophageal reflux 2.
- Aggressive medical therapy is necessary to prevent these complications 2.
- Surgical options should be considered on a case-by-case basis, taking into account the individual patient's disease severity and medical history 5, 3, 4.