From the Guidelines
The stepwise management of peptic stricture begins with proton pump inhibitor (PPI) therapy to control acid reflux, using medications like omeprazole 20-40 mg daily or esomeprazole 40 mg daily, and endoscopic dilation is the cornerstone of treatment, typically starting with through-the-scope balloon dilators or Savary-Gilliard bougies, with the goal of achieving a luminal diameter of ≥15 mm, as recommended by the most recent guidelines 1.
Key Considerations
- PPI therapy should be maintained indefinitely to reduce the risk of stricture recurrence and promote healing of oesophagitis, as supported by high-quality evidence 1.
- Endoscopic dilation sessions should be spaced 1-2 weeks apart, with the goal of achieving easy passage of a ≥15 mm dilator, and symptomatic improvement, as recommended by the guidelines 1.
- The "rule of three" should be followed, limiting each session to three consecutive dilator sizes to minimize perforation risk, although this is not strictly evidence-based 1.
- For refractory strictures, options include steroid injection, incisional therapy, or temporary stent placement, and severe cases may require surgical intervention, as discussed in the guidelines 1.
Treatment Approach
- Initial dilation aims for 12-15 mm diameter, with subsequent sessions spaced 2-3 weeks apart until adequate luminal patency is achieved.
- Patients should avoid NSAIDs, elevate the head of bed, and follow dietary modifications (avoiding large meals, acidic foods, and eating 3 hours before bedtime) to reduce symptoms and promote healing.
- Success is measured by symptom resolution and the ability to maintain adequate oral intake without frequent dilations, as supported by the guidelines 1.
Refractory Strictures
- A stricture should be considered refractory after an inability to maintain a luminal diameter of ≥14 mm after five sequential dilatation sessions, as defined by the guidelines 1.
- Options for refractory strictures include steroid injection, incisional therapy, or temporary stent placement, and severe cases may require surgical intervention, as discussed in the guidelines 1.
From the Research
Stepwise Management of Peptic Stricture
The management of peptic stricture involves a stepwise approach to relieve dysphagia and heal associated esophagitis.
- The initial goal of therapy is to relieve dysphagia, which can be accomplished using polyethylene or mercury-filled dilators or balloons 2.
- An equally important therapeutic objective is the complete healing of associated esophagitis using proton pump inhibitors (PPIs) 2.
- PPIs, such as omeprazole, lansoprazole, and pantoprazole, are effective in the treatment of acid peptic disorders, including peptic stricture 3, 4, 5.
- The choice of PPI and dosage may vary depending on the individual patient and the severity of the stricture 4, 5.
- In some cases, surgical treatment may be reserved for patients with intractable esophagitis, irreversibly damaged esophagus, or extraesophageal manifestations 2.
Treatment Options
- Omeprazole, lansoprazole, and pantoprazole have been shown to be effective in the treatment of peptic stricture 3, 4, 5.
- A comparison of omeprazole, lansoprazole, and pantoprazole in the maintenance treatment of severe reflux oesophagitis found that omeprazole was superior to lansoprazole and pantoprazole in maintaining remission 4.
- Lansoprazole has been shown to be effective in the treatment of erosive reflux oesophagitis, active gastric ulcer, and active duodenal ulcer 5.
- High-dose PPIs may be beneficial in patients with high-risk peptic ulcer bleeding, while standard-dose PPIs may be sufficient for patients with lower risk 6.
Considerations
- The dosage and duration of PPI therapy should be individualized based on the patient's response and the severity of the stricture 3, 5.
- Patients with severe liver disease may require dosage adjustments when taking lansoprazole 3.
- The use of PPIs should be balanced with the potential risks and benefits, including the risk of adverse effects and interactions with other medications 3, 5.