What are the guidelines for pyloric dilatation in post-corrosive injury?

Guidelines for Pyloric Dilatation in Post-Corrosive Injury

Endoscopic dilatation is the first-line treatment for pyloric strictures following corrosive injury, typically started 3-6 weeks after ingestion, with a time interval between dilatations of less than 2 weeks until a target diameter of 14mm is achieved. 1, 2

Assessment and Timing

Initial Evaluation

• Perform upper gastrointestinal endoscopy within 12-48 hours after corrosive ingestion to determine prognosis and management 1, 2
• Consider contrast-enhanced CT scan 3-6 hours post-ingestion to assess extent of injury and detect transmural necrosis 2
• CT classification for detecting injuries:
  • Grade I: Mild injury
  • Grade IIa: Moderate injury without necrosis
  • Grade IIb: Moderate injury with necrosis
  • Grade III: Transmural necrosis (requires surgical intervention) 2

Timing of Dilatation

• Avoid dilatation within 3 weeks of initial caustic ingestion to reduce risk of perforation 1
• Begin dilatation procedures between 3-6 weeks after ingestion when healing of acute injuries has occurred 1, 2
• Schedule dilatation sessions at intervals of less than 2 weeks 1

Dilatation Technique

Method

• Either bougie or balloon dilators can be used; there is no clear advantage of one technique over another 1
• Consider ultrathin endoscope-assisted method for traversing guidewire during dilatation in difficult cases 3
• Target diameter for successful dilatation is 14mm 3
• Perform dilatation under endoscopic or fluoroscopic control based on clinician's expertise 1

Protocol

• Perform weekly or two-weekly dilatation sessions until easy passage of a ≥14-15 mm dilator is achieved along with symptomatic improvement 1, 3
• Simple strictures may require 1-2 procedures, while complex strictures may need 2-15 procedures to achieve target diameter 3

Management of Complications and Refractory Cases

Refractory Strictures

• A stricture is considered refractory after inability to maintain a luminal diameter of ≥14 mm after five sequential dilatation sessions 1-2 weeks apart 1
• Consider discussion with or referral to centers with expertise in treatment of refractory strictures 1
• Pyloric dilatation has a lower success rate compared to esophageal dilatation, with higher rates of recurrent and refractory strictures 3

Surgical Options

• Consider surgical intervention when endoscopic dilatation fails 4
• Surgical options based on extent of injury include:
  • Pyloroplasty (Heineke-Mikulicz or Finney) for moderate mucosal injury with partially obstructed but viable pylorus 5, 6
  • Billroth I procedure for severely injured mucosa with complete pyloric obstruction 5, 6
  • Other options: antrectomy, antroplasty, gastrojejunostomy based on extent of injury 7

Follow-up and Monitoring

• Provide patients with contact information for the on-call team should they experience chest pain, breathlessness, or become unwell after dilatation 1
• Offer proton pump inhibitor therapy after dilatation to reduce acid secretion and potential worsening of strictures 1, 2
• Regular endoscopic surveillance is recommended due to increased risk of malignancy 2
• Psychiatric evaluation is mandatory for all patients prior to discharge, especially for intentional ingestions 2

Special Considerations

• Perforation risk is higher for caustic strictures compared to standard benign esophageal stricture dilatation (0.4-32%) 1
• Complication rate is lower when performed by experienced practitioners 1
• Ongoing inflammation and fibrosis are linked to recurrent and refractory strictures 3

The management of pyloric strictures due to corrosive injury requires a systematic approach with careful timing of interventions and close monitoring for complications. Early surgical intervention should be considered when endoscopic dilatation fails or is not feasible due to the extent of injury.