What is the workup and management for a patient with dysphagia and esophageal stenosis?

Workup and Management of Dysphagia and Esophageal Stenosis

Patients with dysphagia and esophageal stenosis should undergo upper gastrointestinal endoscopy as the initial diagnostic procedure, followed by appropriate dilatation therapy based on stricture etiology, with regular follow-up sessions until achieving a minimum 15mm luminal diameter and symptomatic improvement. 1

Diagnostic Workup

Initial Evaluation

• Barium esophagram: To define the location, length, diameter, and complexity of stricture
• Upper endoscopy: Essential for direct visualization, biopsy, and assessment of stricture characteristics
  • Take multiple biopsies (distal, mid, and proximal esophagus) to exclude:
    • Malignancy
    • Eosinophilic esophagitis (especially in Schatzki's rings) 1
  • Assess stricture features:
    • Length (>2cm = complex)
    • Angulation
    • Diameter
    • Location (upper third carries higher complication risk)

Stricture Classification

1. Simple strictures: Short (<2cm), straight, allow passage of endoscope
2. Complex strictures: Long (>2cm), angulated, severely narrowed, or multiple
3. Refractory strictures: Unable to maintain ≥14mm diameter despite 5 dilatation sessions at 2-week intervals

Management Algorithm by Stricture Etiology

1. Peptic Strictures

• First-line: High-dose PPI therapy + endoscopic dilatation 1
  • PPI reduces need for repeat dilatations and recurrence rates
  • Choose PPI over H2 receptor antagonists (superior efficacy) 1
• Dilatation technique:
  • Bougie or balloon dilators (15-18mm target)
  • Weekly/bi-weekly sessions until ≥15mm diameter achieved 1

2. Schatzki's Rings

• Only dilate symptomatic rings (not incidental findings) 1
• Technique: Single dilatation session to large diameter (16-20mm) 1
• Alternatives: Electrosurgical incision is effective 1
• Post-procedure: PPI therapy to reduce relapse 1

3. Achalasia

• Technique: Pneumatic balloon dilatation
  • First session: 30mm balloon 1
  • Second session (2-28 days later): 35mm balloon 1
  • Consider repeat dilatations during follow-up 1
• Post-procedure:
  • PPI therapy (10-40% develop GERD) 1
  • Consider water-soluble contrast swallow to screen for perforation 1

4. Eosinophilic Esophagitis

• Approach: Trial of medical/dietary therapy before dilatation unless high-grade stenosis present 1
• Technique:
  • More conservative approach than with other benign strictures 1
  • Gradual dilatation with target of 15-18mm
  • Limit progression to ≤3mm per session after resistance 1
  • Multiple sessions often required 1

5. Refractory Strictures

• Optimize medical therapy: Ensure high-dose PPI before defining as refractory 1
• Consider referral to centers with expertise in refractory strictures 1
• Advanced techniques:
  • Intralesional steroid therapy (0.5mL aliquots of triamcinolone 40mg/mL to four quadrants) for strictures with inflammatory component 1
  • Incisional therapy for refractory Schatzki's rings and anastomotic strictures 1
  • Temporary placement of fully covered self-expanding removable stents (4-8 weeks) 1
  • Consider biodegradable stents in selected cases 1
  • Self-bougienage for selected patients with short proximal strictures 1
  • Surgery for non-responders 1

6. Post-surgical Anastomotic Strictures

• Technique: Standard dilatation with steroid injection for refractory cases 1
• Alternative: Needle knife incision 1

7. Caustic Strictures

• Timing:
  • Perform endoscopy within 12-48 hours after caustic ingestion 1
  • Avoid dilatation within 3 weeks of initial caustic ingestion 1
  • Consider interval between dilatations of <2 weeks 1

8. Complete Obstruction

• Technique: Consider combined anterograde and retrograde dilatation (CARD) under fluoroscopic guidance 1
  • Use guidewire to navigate through obstruction 1
  • Perform subsequent dilatation using balloon or bougie 1

Post-Dilatation Care

Immediate Monitoring

• Monitor patients for at least 2 hours in recovery 1
• Ensure patients are tolerating water before discharge 1
• Provide clear written instructions on diet, fluids, and medications 1
• Provide contact information for on-call team 1

Complication Surveillance

• Suspect perforation with:
  • Persistent chest pain
  • Breathlessness
  • Fever
  • Tachycardia 1
• If perforation suspected:
  • Perform CT scan with oral contrast 1
  • Consider immediate treatment with fully covered self-expanding metal stent 1

Follow-up Protocol

• Perform weekly or two-weekly dilatation sessions until:
  • Easy passage of ≥15mm dilator achieved
  • Symptomatic improvement documented 1
• Long-term follow-up is essential as dysphagia may recur in up to 36% of patients regardless of treatment approach 1

Technical Considerations

• Use carbon dioxide insufflation instead of air during endoscopy for complex strictures 1
• Use fluoroscopic guidance for refractory or complex strictures 1
• Choose dilator type (bougie vs balloon) based on stricture characteristics 1

Pitfalls and Caveats

• Perforation risk is higher with:
  • Upper third esophageal strictures
  • Complex or long strictures
  • Eosinophilic esophagitis 1
• Consider alternative neuromuscular causes if dysphagia persists despite adequate dilatation 1
• Stent migration occurs in approximately 30% of cases 1
• Avoid partially or uncovered metal stents due to risk of embedding 1