What are the treatment options for esophageal stricture?

Treatment of Esophageal Stricture

Endoscopic dilatation is the first-line treatment for esophageal strictures, with either balloon or wire-guided bougie dilators providing effective relief in most cases. 1

Initial Approach to Esophageal Strictures

Diagnostic Evaluation

• Upper endoscopy with biopsy to confirm diagnosis and exclude malignancy
• Barium esophagram to assess stricture length, diameter, and complexity
• Classify stricture as simple (focal, straight, allows endoscope passage) or complex (>2cm, tortuous, narrow diameter) 2

Primary Treatment: Endoscopic Dilatation

• Use either balloon or wire-guided bougie dilators based on stricture characteristics 1
• Target dilatation between 13-20mm in diameter for optimal relief 3
• For very narrow strictures:
  • Limit initial dilatation to 10-12mm diameter (30-36F)
  • Use no more than three successively larger diameter increments in a single session 1

Safety Considerations

• Use wire-guided or endoscopically controlled techniques for all patients 1
• Perform dilatation without fluoroscopy for simple strictures 1
• Use fluoroscopic guidance for high-risk strictures (post-radiation, caustic), or those that are long, angulated, or multiple 1
• Monitor patients for at least 2 hours post-procedure 1
• Suspect perforation with persistent chest pain, fever, breathlessness, or tachycardia 1

Management Based on Stricture Etiology

Peptic Strictures

• Maximize PPI therapy (consider twice-daily dosing) 1, 3
• Typically require fewer dilatation sessions (median of 3) compared to other etiologies 4
• Patients lacking heartburn or reporting weight loss at initial presentation may require more frequent dilations 5

Post-Surgical Anastomotic Strictures

• Require median of 5 dilatation sessions 4
• Consider endoscopic radial incision (ERI) as initial treatment, which shows lower re-stricture rates (37.9% vs 61.8%) and more prolonged patency compared to balloon dilatation 6
• Consider steroid injections (0.5mL aliquots of triamcinolone 40mg/mL to four quadrants) to reduce frequency of repeat dilatations 1

Caustic Strictures

• Perform upper GI endoscopy within first 12-48 hours after caustic ingestion 1
• Avoid dilatation within 3 weeks of initial caustic ingestion 1, 3
• Use shorter intervals between dilatations (<2 weeks) 1, 3
• Require median of 5 dilatation sessions 4
• Higher perforation risk compared to other stricture types 1

Management of Refractory Strictures

A stricture is considered refractory when unable to maintain a luminal diameter ≥14mm after five sequential dilatation sessions 1-2 weeks apart or maintain target diameter for 4 weeks once reached 1, 3.

Treatment Options for Refractory Strictures

1. Intralesional Steroid Therapy

   • Recommended for strictures with evidence of inflammation 1
   • Inject 0.5mL aliquots of triamcinolone 40mg/mL to all four quadrants 1, 3
   • Most effective for peptic strictures; less effective for anastomotic and caustic strictures 1

2. Incisional Therapy

   • Consider for refractory Schatzki's rings and anastomotic strictures 1, 3
   • Perform radial incisions parallel to longitudinal axis of esophagus 1
   • Most effective for short strictures (<1.5cm) 1, 3

3. Temporary Stent Placement

   • Offer when previous methods have been unsuccessful 1
   • Fully covered self-expanding removable stents provide complete relief in approximately 40% of cases 1, 3
   • Metal stents show better outcomes than plastic stents with lower migration rates 1
   • Optimal duration of stent placement is 4-8 weeks 1
   • Be aware of complications: stent migration (30%), chest pain, bleeding, perforation 1

4. Self-Bougienage

   • Consider teaching selected, self-motivated patients with short proximal strictures 1

5. Surgical Intervention

   • Offer surgery to patients who do not respond or are intolerant to other measures 1
   • Consider esophageal bypass for extensive, refractory caustic strictures 3

Complications and Follow-up

• Perforation risk is 0.4% per session (higher in complex strictures) 4
• Monitor for signs of perforation: persistent chest pain, fever, breathlessness, tachycardia 1
• Perform biopsies and imaging when restenosis occurs rapidly to exclude occult malignancy 3
• Long-term follow-up is essential due to increased risk of esophageal carcinoma in certain stricture types 3

Endoscopic dilatation without fluoroscopy is safe and effective in relieving dysphagia caused by benign strictures of different causes, with a 93.5% success rate, though repeated sessions are often necessary due to stricture recurrence 4.