What is the treatment for esophageal stricture causing Gastroesophageal Reflux Disease (GERD)?

Treatment for Esophageal Stricture Causing GERD

The primary treatment for esophageal stricture secondary to GERD is endoscopic dilation combined with high-dose proton pump inhibitor (PPI) therapy to prevent recurrence. 1

Initial Management Strategy

PPI Therapy as Foundation

• Initiate high-dose PPI therapy immediately for all patients with GERD-related strictures, as this reduces the need for initial dilation and prevents stricture recurrence after dilation. 1
• Use omeprazole 20 mg or lansoprazole 30 mg once daily, taken 30-60 minutes before the first meal, escalating to twice-daily dosing if needed. 2
• PPIs are superior to H2-receptor antagonists, which are ineffective in reducing repeat dilation requirements and less effective for healing esophagitis. 1

Endoscopic Dilation Protocol

• Perform graded endoscopic dilation using bougie or balloon dilators to achieve a target diameter of ≥15 mm. 1
• Use weekly or two-weekly dilation sessions until easy passage of a ≥15 mm dilator is achieved with symptomatic improvement. 1
• A stepwise approach to 13-20 mm provides good relief in 85-93% of peptic stricture cases. 1

Management of Refractory Strictures

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

Before Declaring Refractory Status

• Ensure optimal management of ongoing inflammation with high-dose PPI therapy before redefining a stricture as refractory—this is critical as inadequate acid suppression is a common pitfall. 1
• Consider alternative neuromuscular causes (achalasia, esophageal dysmotility) in patients with ongoing dysphagia despite seemingly adequate esophageal diameter. 1

Advanced Treatment Options for Refractory Cases

Intralesional Steroid Therapy:

• Use intralesional triamcinolone (0.5 mL aliquots of 40 mg/mL to all four quadrants) combined with dilation in refractory strictures with evidence of inflammation, assuming anti-reflux therapy has been maximized. 1
• This approach reduces the number of repeat dilations and increases the dysphagia-free period for peptic strictures specifically. 1
• Note: This is less effective for anastomotic or caustic strictures and may increase complications in those etiologies. 1

Temporary Stent Placement:

• Offer fully covered self-expanding removable stents when previous methods have failed to maintain adequate esophageal patency, with complete dysphagia relief in approximately 40% of patients. 1
• Optimal stent duration is typically 4-8 weeks, though this varies by stricture etiology and length. 1

Incisional Therapy:

• Consider radial incisions using needle or IT knife at centers experienced in these techniques, particularly for short strictures (<1.5 cm). 1

Fluoroscopic Guidance:

• Use fluoroscopic guidance during dilation of refractory strictures to improve safety and precision. 1

Surgical Intervention

• Refer patients for antireflux surgery only when they are intolerant of acid suppressive therapy or have persistent troublesome symptoms (especially regurgitation) despite optimized PPI therapy. 1
• Surgery should be weighed against new post-operative symptoms including dysphagia, flatulence, inability to belch, and bowel symptoms. 1
• Do NOT recommend surgery for patients symptomatically well-controlled on medical therapy or as an antineoplastic measure in Barrett's esophagus. 1
• Esophagectomy is reserved for rare cases of long-segment stenosis (>2 cm) that fail all endoscopic approaches. 3, 4

Critical Pitfalls to Avoid

• Never discontinue or reduce PPI therapy prematurely—inadequate acid suppression is the most common cause of stricture recurrence. 1
• Avoid declaring a stricture "refractory" without first maximizing PPI therapy to twice-daily dosing. 1
• Do not use H2-receptor antagonists as primary therapy—they are ineffective for stricture prevention. 1
• Suspect perforation immediately if patients develop chest pain, breathlessness, fever, or tachycardia post-dilation; perform urgent CT with oral contrast. 1
• Refer complex strictures (>2 cm, angulated, irregular, severely narrowed) to centers with expertise in refractory stricture management. 1

Follow-Up and Monitoring

• Provide patients with contact information for the on-call team for post-procedure complications. 1
• Predictors for repeated dilation include non-peptic causes, fibrous strictures, and maximum dilator size <14 mm. 1
• Carefully selected patients with recurrent proximal strictures may be taught self-bougienage. 1, 5