What is the recommended treatment approach for esophageal strictures in patients with Eosinophilic Esophagitis (EoE) using endoscopic dilation?

Endoscopic Dilation for EoE Strictures

Offer endoscopic dilation combined with anti-inflammatory therapy (topical steroids or dietary elimination) for patients with EoE strictures, as this combined approach provides superior long-term outcomes compared to dilation alone. 1

When to Perform Dilation

Immediate Dilation Indications (First-Line)

• Offer dilation as first-line treatment for acute symptoms including food bolus obstruction and daily dysphagia, even before initiating medical therapy 1
• Perform dilation in patients with established tight strictures (<7 mm caliber), narrow caliber esophagus (<13 mm), or those who fail to respond to diet or drugs 1

Preferred Approach for Non-Acute Cases

• Start topical steroids before dilation when possible, as preliminary topical steroid therapy followed by dilation is more cost-effective than using dilation as first treatment 1
• Continue anti-inflammatory therapy (topical steroids or dietary elimination) after dilation to prevent or delay symptom recurrence 1

Safety Profile

Reassurance for Patients

• Reassure patients that dilation in EoE carries no higher perforation risk than dilation for other benign esophageal diseases (peptic stricture, achalasia), with perforation rates of 0.38-0.8% 1
• Inform patients that chest pain after dilation is common (occurs in 5-74% depending on reporting method) and can be managed conservatively with fluids and analgesia 1
• Mucosal tears occur in approximately 8-9% of cases and should be considered markers of successful dilation rather than complications, managed conservatively 1

Technical Approach

• Use either balloon or bougie dilators—both are equally safe and effective, though balloon dilators may be preferred as they allow immediate assessment of esophageal injury and reassure operators that perforation is not occurring 1
• Employ gradual dilation with target diameter of 16-18 mm, using sessions separated by 3-4 weeks 1
• Limit progression to 3 mm or less per session after resistance is encountered 1
• Exercise particular caution with tight strictures <7 mm caliber 1

Expected Outcomes and Follow-Up

Symptom Response

• Inform patients that symptom response after dilation typically lasts up to 1 year 1
• Immediate symptomatic improvement occurs in approximately 95% of EoE patients with strictures 2
• Clinical improvement is documented in 75% of patients in meta-analyses 1

Repeat Procedures

• Offer repeat dilation if symptoms of severe dysphagia recur or if symptomatic stricture is diagnosed during follow-up 1
• Multiple dilation sessions are often required for high-grade esophageal stenosis 1
• Longer intervals between dilations are observed when patients receive concurrent topical steroid treatment 1

Monitoring

• Perform repeat endoscopy at 6-12 weeks after initial dilation 1
• Continue maintenance treatment with topical steroids or dietary elimination after dilation 1

Critical Clinical Outcomes

Clinical outcomes are significantly better when therapeutic dilation is combined with effective anti-inflammatory therapy such as topical steroids, as dilation alone does not address the underlying inflammatory process 1

Reversibility of Severe Disease

• Most patients (89%) with severe strictures (≤10 mm diameter) achieve esophageal diameter ≥13 mm with treatment 3
• 65% of patients with severe strictures achieve diameter ≥15 mm 3
• Initial esophageal diameter and histologic remission are the most significant factors associated with achieving diameter ≥15 mm 3

Common Pitfalls to Avoid

• Never use dilation as monotherapy without initiating concurrent anti-inflammatory treatment, as this fails to address underlying inflammation and increases need for repeated procedures 1
• Do not delay dilation in patients with acute food bolus obstruction or severe daily dysphagia—these require immediate intervention 1
• Avoid overly aggressive dilation in a single session; use gradual approach with multiple sessions separated by 3-4 weeks 1
• Do not assume chest pain after dilation represents perforation—it is common and usually managed conservatively 1