Can peptic stricture resolve with Proton Pump Inhibitors (PPI) or is dilation required?

From the Guidelines

Peptic strictures can resolve with PPI therapy alone in some cases, but often require a combination of PPI therapy and endoscopic dilation for effective management. The decision to use PPI therapy alone or in combination with dilation depends on the severity of the stricture and the presence of symptoms. According to the UK guidelines on oesophageal dilatation in clinical practice 1, PPI therapy can reduce the need for oesophageal dilatation in patients with GORD and dysphagia. The guidelines recommend offering PPI therapy to patients with GORD and dysphagia, as this treatment has been shown to reduce the need for oesophageal dilatation (GRADE of evidence: high; strength of recommendation: strong) 1.

Some key points to consider when managing peptic strictures include:

• PPI therapy can help prevent stricture progression by reducing acid production and allowing some healing 1
• Endoscopic dilation is necessary in most cases to physically widen the narrowed esophageal lumen 1
• The standard approach involves a combination of dilation procedures along with long-term PPI therapy 1
• After successful dilation, patients should continue PPI maintenance therapy indefinitely to prevent stricture recurrence 1
• PPI therapy is more effective than H2 receptor antagonists in reducing the need for repeat dilatation and providing symptom relief from GORD and dysphagia 1

In terms of specific treatment recommendations, PPI therapy should be offered to patients with GORD and dysphagia, and after endoscopic dilatation for peptic strictures, to reduce recurrence rate 1. The choice of PPI therapy, such as omeprazole 20-40mg daily, esomeprazole 20-40mg daily, or pantoprazole 40mg daily, will depend on the individual patient's needs and medical history. Overall, a combination of PPI therapy and endoscopic dilation is often necessary to effectively manage peptic strictures and prevent recurrence.

From the Research

Peptic Stricture Resolution with PPI

• Peptic stricture can resolve with the use of proton pump inhibitors (PPIs) such as omeprazole, as shown in studies 2, 3, 4, 5.
• The management of peptic oesophageal stricture has been improved with the development of inhibitors of gastric acid secretion, including H(+) + K(+) + ATPase inhibitors like omeprazole 2.
• Omeprazole has been shown to be effective in reducing the number of oesophageal dilatations required in patients with peptic stricture formation, with a reduction of up to 60% 2.
• Esophagitis healing improves dysphagia and decreases dilatation need in patients with peptic stricture, and omeprazole heals esophagitis and relieves dysphagia more efficaciously than H2-receptor antagonists (H2RA) 3.

Predictors of Stricture Recurrence

• The persistence of heartburn after dilation is a strong predictor for early symptomatic recurrence of benign esophageal peptic strictures, despite a high rate of PPI use 6.
• Nonpeptic strictures are more likely to have early recurrences and are therefore more difficult to manage 6.
• A narrower stricture diameter is also a predictor for early recurrence of benign esophageal strictures 6.

Treatment with Omeprazole

• Omeprazole is a safe and effective maintenance treatment for preventing relapse of complicated reflux oesophagitis, with a highly significant greater rate of oesophagitis healing and fewer dilatations compared to H2RA 4.
• Acid suppression with omeprazole can reduce pathological oesophageal acid exposure as effectively as successful anti-reflux surgery, and can resolve peptic stricture during effective gastric acid inhibition 5.