What is the management plan for a patient with esophageal narrowing confirmed by neck CT, scheduled for endoscopy?

Management of Esophageal Narrowing Requiring Endoscopy

The patient with esophageal narrowing confirmed by neck CT should be admitted for endoscopy with possible dilatation, following proper pre-procedure preparation including fasting for 4-6 hours and appropriate sedation. 1

Pre-Procedure Preparation

Fasting Requirements

• Ensure patient fasts for 4-6 hours before the procedure to empty the esophagus and stomach 1
• Patients with achalasia may require longer fasting periods due to esophageal stasis 1

Medication Management

• Discontinue oral anticoagulants in low-risk thromboembolic patients prior to the procedure 1
• For high-risk thromboembolic patients, discontinue oral anticoagulants and consider bridging with intravenous heparin, stopping 4-6 hours before the procedure 1
• Aspirin and NSAIDs generally do not increase risk of significant bleeding 1
• Provide antibiotic prophylaxis for patients with prosthetic heart valves, previous endocarditis, synthetic vascular grafts, or neutropenia 1

Sedation and Analgesia

• Administer intravenous sedation with a benzodiazepine and an opioid analgesic at minimum 1
• Consider propofol sedation (administered by qualified personnel) or general anesthesia for complex cases 1
• Ensure opioid and benzodiazepine antagonists are immediately available 1

Procedure Details

Personnel Requirements

• Procedure should be performed by an experienced endoscopist supported by at least two trained assistants 1
• Ensure surgical support is available in case of perforation 1
• Perform the procedure in a fully equipped endoscopy room with access to X-ray screening 1

Dilatation Technique

• Use either balloon or wire-guided bougie dilators (avoid weighted bougies with blind insertion) 1
• For very narrow strictures not passable by adult gastroscope, limit initial dilatation to 10-12 mm diameter 1
• Consider using no more than three successively larger diameter increments in a single session 1
• Use wire-guided or endoscopically controlled techniques to enhance safety 1
• Consider fluoroscopic guidance for high-risk strictures (post-radiation, caustic), long, angulated, or multiple strictures 1
• Use carbon dioxide insufflation instead of air to minimize luminal distension and post-procedural pain 1

Post-Procedure Care

Monitoring

• Monitor the patient for at least 2 hours in the recovery room 1, 2
• Regularly check vital signs including pulse, blood pressure, and temperature 2
• Ensure patient can tolerate oral fluids before discharge 1

Complication Surveillance

• Suspect perforation if patient develops persistent chest pain, fever, breathlessness, or tachycardia 1, 2
• Perform CT scan with oral contrast if perforation is suspected (more sensitive than conventional contrast studies) 1, 2
• Conduct endoscopic re-inspection if symptoms develop while still in the procedure room 1, 2

Follow-up Plan

• Provide clear written instructions about expected symptoms, diet, medications, and emergency contact information 1, 2
• Consider weekly or two-weekly dilatation sessions until easy passage of a ≥15 mm dilator is achieved along with symptomatic improvement 1
• Consider proton pump inhibitor therapy to reduce acid-related discomfort 2

Special Considerations

For Upper Esophageal Sphincter Dilatation

• Consider dilatation for dysphagia with disordered upper esophageal sphincter opening, post-cricoid web, or cricopharyngeal bar 1

For Achalasia

• Perform dilatation with pneumatic balloons 30-40 mm in diameter, starting at 30 mm in the first session 1
• Schedule a second dilatation session 2-28 days later with a larger 35 mm balloon 1

Potential Complications and Management

• Perforation is the principal risk of esophageal dilatation 1
• Iatrogenic perforation is a medical emergency requiring immediate assessment by an experienced physician and surgeon 1, 2
• Treatment options include surgical, endoscopic (including immediate stent placement), or conservative management 1, 2

By following this structured approach to the management of esophageal narrowing, clinicians can optimize patient outcomes while minimizing the risk of complications.