What is the initial treatment for a patient with an esophageal stricture?

Initial Treatment for Esophageal Stricture

The initial treatment for a patient with esophageal stricture is endoscopic dilatation using either balloon or wire-guided bougie dilators, with the choice individualized based on stricture characteristics. 1, 2

Evaluation Before Dilatation

• Determine if the stricture is simple (short <2cm, concentric, straight) or complex (longer ≥2cm, angled, irregular) as this affects treatment approach and prognosis 1
• Assess stricture diameter, length, and underlying pathology to guide initial dilator choice 1
• Consider fluoroscopic guidance for high-risk strictures (post-radiation, caustic), long, angulated, or multiple strictures 1

Dilatation Technique

• Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques to enhance safety 1
• Avoid weighted (Maloney) bougies with blind insertion as safer dilators are available 1
• For very narrow strictures not passable by adult gastroscope, limit initial dilatation to 10-12 mm in diameter 1
• For filiform strictures, target an even smaller initial diameter (≤9 mm) 1
• Follow the "Rule of Three" - use no more than three successively larger diameter increments in a single session 1

Treatment Protocol

• Perform dilatations weekly or biweekly until achieving a luminal diameter of ≥15 mm along with symptomatic improvement 2
• Simple strictures typically require only 1-3 dilatation sessions, with a maximum of five dilatations resolving symptoms in >95% of patients 1
• Complex strictures are more difficult to treat and have a tendency to be refractory or recur despite dilatation 1
• Offer intravenous sedation with a benzodiazepine and an opioid analgesic at minimum for patient comfort 1

Special Considerations by Stricture Type

Peptic Strictures

• Ensure optimal management of ongoing inflammation with high-dose PPI therapy before defining a stricture as refractory 1, 3
• Combine aggressive medical therapy with bougienage for safe and effective treatment 3

Caustic Strictures

• Perform upper GI endoscopy within the first 12-48 hours after caustic ingestion 1
• Consider avoiding dilatation within 3 weeks of initial caustic ingestion 1
• Use a shorter time interval between dilatations (<2 weeks) 1
• Note that perforation rates are higher than with other benign strictures 2

Eosinophilic Esophagitis (EoE)

• Offer dilatation as first-line treatment in patients with acute symptoms such as food bolus obstruction and daily dysphagia 1
• Consider starting other treatments for EoE (diet, topical steroids) before or alongside dilatation 1
• Inform patients that chest pain after dilatation is common in EoE 1

Management of Refractory Strictures

• A stricture is considered refractory when unable to maintain a luminal diameter of ≥14 mm after five sequential dilatation sessions 2
• Use intralesional steroid therapy (0.5 mL aliquots of triamcinolone 40 mg/mL to the four quadrants) combined with dilatation in refractory strictures with evidence of inflammation 1
• Consider incisional therapy for refractory Schatzki's rings and anastomotic strictures 1
• Offer temporary placement of fully covered self-expanding removable stents when previous methods have failed 1, 4

Post-Procedure Care

• Monitor patients for at least 2 hours in the recovery room 2
• Suspect perforation if patients develop pain, breathing difficulty, fever, or tachycardia 2
• Perform repeat endoscopy or injection of contrast after dilatation if perforation is suspected 1
• Provide clear written instructions about liquids, diet, and medications after the procedure 2

Complications and Their Management

• Transient chest pain is common after dilatation, but persistent pain should prompt CT with oral contrast to evaluate for perforation 2
• The overall perforation rate for benign esophageal stricture dilatation is approximately 0.4%, but can be up to 32% for caustic strictures 2
• Consider surgical management only for patients with refractory strictures not responding to multiple endoscopic interventions 5, 6