Treatment Options for Esophageal Strictures
Endoscopic dilatation is the first-line treatment for esophageal strictures, with a stepwise approach to dilatation between 13-20 mm providing good relief in 85-93% of cases. 1
Initial Management Approach
Standard Dilatation Therapy
- Use either bougie or balloon dilators based on stricture characteristics (length, location, cause)
- Target dilatation to between 13-20 mm in diameter
- For simple strictures (focal, straight, allowing endoscope passage):
- Typically requires 3 sessions for peptic strictures
- May require 5 sessions for postsurgical or caustic strictures 2
- Monitor closely post-dilatation for signs of perforation (pain, breathlessness, fever, tachycardia) 1
Acid Suppression Therapy
- Maximize proton pump inhibitor (PPI) therapy for peptic strictures
- Standard dose PPI is more effective than H2 receptor antagonists
- Consider twice-daily PPI dosing when restenosis occurs rapidly 1
Management of Refractory Strictures
A stricture is considered refractory when unable to maintain a luminal diameter ≥14 mm after five sequential dilatation sessions 1-2 weeks apart or maintain target diameter for 4 weeks once reached. 1
Advanced Endoscopic Options
Intralesional Steroid Therapy
- Recommended for refractory strictures with evidence of inflammation
- Involves injection of 0.5 mL aliquots of 40 mg/mL triamcinolone to all four quadrants
- Most effective for peptic strictures; less effective for anastomotic and caustic strictures 1
Incisional Therapy
- Consider for refractory Schatzki's rings and anastomotic strictures
- Involves radial incisions parallel to longitudinal axis of esophagus
- Most effective for short strictures (<1.5 cm) 1
Stent Placement
- Consider for persistent strictures after other methods fail
- Metal stents show better outcomes than plastic stents (lower migration rates)
- Stents typically left in place for 4-8 weeks (maximum 3 months)
- Provides complete relief of dysphagia in approximately 40% of cases
- Complications include stent migration (30%), chest pain, bleeding, and perforation (20%) 1
Special Considerations for Caustic Strictures
- Avoid dilatation within 3 weeks of initial caustic ingestion
- Use shorter intervals between dilatations (<2 weeks)
- Higher perforation risk compared to other stricture types
- Consider fluoroscopic guidance during dilatation 1, 3
- For extensive, refractory caustic strictures, esophageal bypass surgery may be indicated to preserve native esophagus while creating alternative food passage 3
Surgical Options
- Consider surgical intervention for patients who need frequent dilatation despite PPI treatment
- Options include antireflux surgery for reflux-related strictures
- For extensive caustic strictures, esophageal bypass shows good long-term results with better quality of life than continued dilatation attempts 1, 3
- Colonic interposition between cervical esophagus and stomach may be preferred for severe caustic strictures 4
Follow-up and Monitoring
- Carefully selected patients with recurrent benign strictures may be taught self-dilatation
- Perform biopsies and imaging when restenosis occurs rapidly to exclude occult malignancy
- Long-term follow-up is essential due to increased risk of esophageal carcinoma in certain stricture types 1, 3
Pitfalls and Caveats
- Perforation risk is higher in complex strictures (>2 cm, angulated, irregular, severely narrowed)
- Caustic, radiation-induced, and post-ablative strictures are more likely to be refractory
- Each additional dilatation attempt increases cumulative perforation risk
- Avoid partially or uncovered metal stents due to risk of embedding in the esophageal wall 1
- Psychiatric evaluation is mandatory prior to hospital discharge for patients with caustic strictures 3, 4