What is the initial approach to treating esophageal narrowing?

Initial Approach to Esophageal Narrowing

The initial approach to esophageal narrowing should begin with diagnostic endoscopy and biopsy to determine the underlying cause, followed by medical or dietary therapy when appropriate, reserving dilation for symptomatic patients with fixed strictures or high-grade stenosis. 1

Diagnostic Evaluation

Perform diagnostic endoscopy with biopsy as the first step to identify the etiology of esophageal narrowing, obtaining at least 6 biopsies from different anatomical sites. 2 This is critical because the underlying cause (eosinophilic esophagitis, peptic stricture, caustic injury, malignancy) fundamentally determines the treatment approach and affects morbidity outcomes.

• Consider barium esophagram to identify the presence, caliber, and length of the stricture before endoscopy, particularly for complex strictures. 2
• If eosinophilic esophagitis is suspected, discontinue proton pump inhibitors for 3 weeks before endoscopy to avoid masking the diagnosis. 2
• Assess whether the stricture is simple (short <2 cm, concentric, straight, allows endoscope passage) versus complex (≥2 cm, angled, irregular, severely narrowed). 1

Initial Medical Management

Unless a critical stricture exists requiring immediate intervention, initiate medical therapy before performing dilation. 1 This approach reduces the risk of mucosal tearing and perforation during subsequent dilation procedures.

For Eosinophilic Esophagitis:

• Start PPI therapy in patients not previously treated with acid suppression. 1
• If eosinophilic esophagitis persists after PPI trial, initiate topical corticosteroids (swallowed fluticasone or budesonide) or dietary therapy. 1, 3
• Medical or dietary therapy should be attempted prior to performing esophageal dilation whenever possible because expert opinion suggests residual strictures unresponsive to medical therapy may be more safely dilated. 1

For Peptic Strictures:

• Ensure optimal management of ongoing inflammation with high-dose PPI therapy before defining a stricture as refractory. 4

When to Proceed Directly to Dilation

For high-grade strictures causing critical narrowing or food impaction, dilation before initiation of medical therapy has been well tolerated and effective. 1 This represents an important exception to the medical-therapy-first approach.

• Esophageal dilation is useful for symptomatic patients presenting with symptomatic esophageal narrowing secondary to fixed strictures causing food impaction. 1
• In the absence of high-grade esophageal stenosis, a trial of medical or dietary therapy before performance of esophageal dilation is reasonable. 1

Critical Safety Considerations

The risk of mucosal tearing and perforation is significant in esophageal narrowing, particularly in eosinophilic esophagitis. 1 Multiple studies report esophageal mucosal tearing, significant pain, and rare reports of perforation, with perforation rates ranging from 0.4% to 32% for caustic strictures and 1.1% for benign strictures overall. 1, 4

• A more conservative and careful approach in esophageal dilation technique is advised compared to other benign entities like Schatzki ring or peptic stricture. 1
• Inspection of the esophageal mucosa (radiographic or very gentle endoscopic examination) should be considered following esophageal dilation to assess for laceration injury. 1
• Concern exists that the use of steroids (systemic or topical) may exacerbate the risk of perforation related to dilation, though this is not proven. 1

Common Pitfalls to Avoid

Do not perform dilation as primary therapy without addressing the underlying inflammatory process, as this does not alter the abnormal esophageal histology and leads to high recurrence rates (7-50% requiring repeat dilation within 2-24 months). 1

• Avoid weighted (Maloney) bougies with blind insertion, as safer wire-guided dilators are available. 1, 2
• Do not assume all esophageal narrowing is benign—obtain tissue diagnosis to exclude malignancy, which has a perforation rate of 6.4% with dilation compared to 1.1% for benign strictures. 1
• For caustic strictures, avoid dilation within the first 3 weeks after ingestion. 4

Algorithmic Approach Summary

1. Diagnostic endoscopy with biopsy (≥6 samples from different sites) 2
2. If high-grade stenosis or food impaction: Proceed to dilation 1
3. If not critical: Initiate cause-specific medical therapy:
   • PPI trial for suspected acid-related disease 1
   • Topical steroids or dietary therapy for eosinophilic esophagitis 1, 3
   • High-dose PPI for peptic strictures 4
4. Reassess after 6-8 weeks of medical therapy 1
5. If residual symptomatic stricture: Proceed to dilation with medical therapy continuation 1

This stepwise approach prioritizes patient safety by reducing perforation risk while addressing the underlying inflammatory process that drives stricture formation and recurrence.