What are the indications for esophageal dilation in pediatric patients?

Indications for Esophageal Dilation in Pediatric Patients

The primary indication for esophageal dilation in pediatric patients is symptomatic esophageal narrowing or stricture causing dysphagia or food impaction that has not responded adequately to medical therapy. 1

Primary Indications

• Fixed esophageal strictures causing symptoms:

  • Dysphagia (difficulty swallowing)
  • Food bolus impaction
  • Nutritional compromise
  • Inability to advance diet 1

• Strictures by etiology:

  • Eosinophilic esophagitis (EoE) with stricture formation
  • Post-surgical anastomotic strictures
  • Corrosive/caustic ingestion strictures
  • Congenital esophageal strictures
  • Peptic strictures from severe GERD 2, 3

Timing and Approach

For EoE-Related Strictures:

1. First-line approach: Medical therapy with anti-inflammatory agents (topical steroids, dietary elimination) should be attempted before dilation when possible 1

2. Immediate dilation indications:

   • Tight esophageal stricture impairing swallowing and nutritional intake
   • Food bolus obstruction requiring urgent intervention 1, 4

3. Deferred dilation indications:

   • Persistent symptoms despite adequate anti-inflammatory therapy
   • Fixed fibrotic strictures that won't respond to medical therapy alone 1

Special Considerations

• Pediatric EoE with strictures:

  • Dilation is safe and effective in children with EoE strictures 1
  • Combined approach with medical therapy and dilation shows best outcomes 5
  • In severe cases with moderate-to-severe strictures, systemic steroids may be used before dilation 1

• Technical considerations:

  • Both balloon and bougie dilators are effective and safe in children 3
  • Target diameter typically 15-18mm depending on age and size of child 4
  • Serial dilations in 1-3mm increments are recommended 4

Safety Profile

• Perforation risk: Very low (0.38%) in modern practice, similar to other benign conditions 1
• Common complications:
  • Post-procedural chest pain (most common)
  • Mucosal tears (expected and considered a marker of successful dilation) 1, 4

Optimal Management Algorithm

1. Diagnostic phase:

   • Confirm stricture presence and etiology through endoscopy and biopsy
   • Assess stricture length, diameter, and location 2

2. Treatment decision:

   • For mild strictures: Trial of medical therapy first (especially for EoE)
   • For severe strictures affecting nutrition: Consider immediate dilation 1

3. Post-dilation management:

   • Continue or initiate anti-inflammatory treatment after dilation
   • Follow-up endoscopy at 6-12 weeks to assess response 4
   • Monitor for symptom recurrence and need for repeat dilation

Pitfalls and Caveats

• EoE is the most common cause of spontaneous esophageal perforation - careful technique is essential 1
• Avoid dilation immediately after starting steroids in EoE as this may increase perforation risk 1
• Multiple dilations are often required - parents should be counseled that a single procedure is rarely sufficient 5, 6
• Recurrence rates are high without ongoing medical therapy - combined approach is essential for long-term success 1, 5

Esophageal dilation is a safe and effective procedure in pediatric patients when performed by experienced teams in specialized centers, with complication rates as low as 4.5% and conversion to surgery needed in only 2.2% of cases 2.