What is the approach to managing corrosive poisoning esophageal stricture?

Management of Corrosive Poisoning Esophageal Stricture

Endoscopic dilation is the first-line treatment for corrosive esophageal strictures, typically started 3-6 weeks after ingestion, with reconstructive esophageal surgery considered after 5-7 failed dilation attempts. 1, 2

Initial Evaluation and Diagnosis

• Stricture formation is the most common and disabling long-term complication of corrosive ingestion, typically occurring within 4 months after ingestion
• Dysphagia and regurgitation are the main symptoms requiring immediate upper GI evaluation
• Diagnostic tools:
  • Endoscopy is the main diagnostic tool for evaluating esophageal strictures in symptomatic patients 1
  • CT scan is superior to endoscopy for detecting transmural injuries and predicting stricture formation 2
  • Barium swallow helps assess stricture length, number, and location

Treatment Algorithm

1. Endoscopic Dilation (First-line)

• Timing: Begin 3-6 weeks after ingestion to allow healing of acute injuries 1
• Patient selection: Most appropriate for patients with few (<3) short (<5 cm) esophageal strictures 1
• Technique:
  • Graded stepwise approach to dilation between 13-20 mm provides good relief in 85-93% of cases 1
  • Interval between dilations: 1-3 weeks 1
  • Weekly dilation until easy passage of >14 mm dilator is a common strategy 1
• Expected outcomes:
  • 3-5 sessions typically provide satisfactory results 1
  • Tight strictures may require short-interval redilation 1
  • Predictors for repeated dilation: non-peptic causes (like corrosive), fibrous strictures, and maximum dilator size <14 mm 1

2. Surgical Management

• Indications for surgery:
  • Recurrent failure of endoscopic dilation (after 5-7 failed attempts) 1
  • Strictures >5 cm in length 3
  • Multiple or tortuous strictures 4
  • Perforation during dilation 1
• Surgical options:
  • Transhiatal esophagectomy with gastric pull-up and cervical esophagogastrostomy is a safe procedure for corrosive strictures 5
  • Be aware: Post-surgical anastomotic stenosis may occur in up to 46% of cases, requiring additional dilations 5

Complications and Their Management

• Perforation:

  • Risk factors: Complex strictures, inexperienced operators, blind passage of weighted bougies 1
  • Signs: Persistent pain, breathlessness, fever, tachycardia
  • Diagnosis: Chest X-ray, water-soluble contrast study
  • Management: Immediate surgical consultation; perforation is a medical emergency 1

• Post-dilation stricture recurrence:

  • Consider self-dilation for carefully selected patients with recurrent benign strictures 1
  • Evaluate for other factors contributing to dysphagia, such as associated esophageal motor dysfunction 4

Prognostic Factors

• Factors predicting poor response to dilation:

  • Delay in presentation >1 month after injury
  • Severe pharyngo-esophageal burns
  • Previous esophageal perforation
  • Stricture length >5 cm 3
  • Tortuous strictures 4

• Oesophageal transit time is prolonged in approximately one-third of patients with corrosive strictures despite adequate dilation, suggesting impaired esophageal motility that may contribute to persistent dysphagia 4

Special Considerations

• Pediatric patients:

  • Esophageal rest combined with supporting treatment in the acute phase (including IV fluids, broad-spectrum antibiotics, single-dose steroid, and IV ranitidine) may help prevent stricture development 6
  • Early intervention in cases with poor prognostic factors can prevent fruitless dilations and related complications 3

• Follow-up:

  • Regular endoscopic evaluation to assess response to treatment
  • Long-term follow-up is essential, especially for severe strictures

Endoscopic balloon dilation has been shown to be a safe, effective method for managing esophageal strictures caused by corrosive injury, with good to improved results in most patients 7.