GERD with Esophageal Stricture: Treatment Approach
Patients with GERD and esophageal stricture require both endoscopic dilation and high-dose proton pump inhibitor (PPI) therapy, with PPIs being essential to reduce stricture recurrence after dilation. 1
Immediate Management Strategy
PPI Therapy - The Cornerstone
- Initiate PPI therapy immediately in all patients with GERD and dysphagia, as this reduces the need for esophageal dilation 1
- After endoscopic dilation for peptic strictures, PPI therapy is mandatory to reduce recurrence rates 1
- PPIs are superior to H2 receptor antagonists, which are ineffective in reducing repeat dilation needs, less effective in healing esophagitis, and inferior for symptom relief 1
- Standard dosing is typically once-daily PPI (e.g., omeprazole 20 mg, lansoprazole 30 mg, or esomeprazole 40 mg) taken 30-60 minutes before meals 1, 2
- Patients with strictures require indefinite long-term PPI therapy and should not be weaned off medication 1
Endoscopic Dilation Protocol
- Perform weekly or two-weekly dilation sessions until easy passage of a ≥15 mm dilator is achieved along with symptomatic improvement 1
- Use graded dilation technique to minimize perforation risk 1
- Dilation can be performed under endoscopic or fluoroscopic control based on clinician preference and local expertise 1
Critical Safety Considerations
Post-Procedure Monitoring
- Provide patients with contact information for the on-call team should they experience chest pain, breathlessness, or become unwell after dilation 1
- Consider water-soluble contrast swallow after dilation to screen for perforation, though not essential 1
- Perform endoscopic re-inspection if the patient becomes symptomatic while in the procedure room to assess for perforation 1
Long-Term Management Algorithm
Maintenance Therapy
- Continue at least single-dose PPI indefinitely - this is non-negotiable for patients with peptic strictures 1
- Do not attempt to wean PPIs in stricture patients, unlike uncomplicated GERD where dose reduction is appropriate 1
- Evaluate for Barrett's esophagus during endoscopy, as this would further mandate lifelong PPI therapy 1
Lifestyle Modifications (Adjunctive)
- Weight loss for overweight/obese patients 3
- Elevate head of bed for nighttime symptoms 3
- Avoid lying down for 2-3 hours after meals 3
- Smoking cessation and alcohol limitation 3
When Medical Management Fails
Indications for Surgical Referral
- Recurrent strictures despite optimal medical therapy (PPI compliance and repeated dilations) 1
- Laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options in carefully selected patients with proven GERD 1
- Candidacy requires confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function 1
Common Pitfalls to Avoid
Critical Errors
- Never use H2 receptor antagonists instead of PPIs for stricture management - they are ineffective for preventing stricture recurrence 1
- Do not perform single dilation and discharge without PPI therapy - recurrence is nearly universal without acid suppression 1
- Avoid attempting to wean PPIs in stricture patients during "medication review" - these patients require lifelong therapy 1
Diagnostic Considerations
- Complete endoscopic evaluation must include grading of erosive esophagitis (Los Angeles classification), assessment of hiatal hernia, and inspection for Barrett's esophagus 1
- Consider eosinophilic esophagitis if stricture is refractory to standard therapy - obtain biopsies from distal, mid, and proximal esophagus 1
Expected Outcomes
Healing and Recurrence
- With appropriate PPI therapy after dilation, stricture recurrence rates are significantly reduced compared to no PPI or H2RA therapy 1
- Repeated dilations may still be required in some patients despite optimal medical therapy 1
- Symptom-based approach guides timing of repeat endoscopy - routine surveillance is unnecessary if asymptomatic 1