What is the best management approach for a patient with esophagitis and a history of balloon dilation?

Management of Esophagitis with History of Balloon Dilation

Combine effective anti-inflammatory therapy with topical steroids alongside repeat dilation as needed to achieve optimal clinical outcomes and prevent stricture recurrence. 1

Determine the Underlying Etiology

The management approach depends critically on identifying the cause of esophagitis, as this dictates both medical therapy and dilation strategy:

If Eosinophilic Esophagitis (EoE):

• Start or optimize topical corticosteroids as first-line anti-inflammatory therapy (fluticasone or budesonide), as clinical outcomes are significantly better when therapeutic dilation is combined with effective anti-inflammatory treatment 1
• Medical treatment with topical steroids reduces the development of future strictures 1
• If symptoms recur while on treatment, repeat endoscopy with histology to assess disease activity 1
• Consider twice-daily PPI dosing (e.g., omeprazole 20-40 mg twice daily) rather than once-daily, as this achieves higher histologic remission rates (52.8-54.3% vs 10-11.8%) regardless of total daily dose 2

If Peptic/Reflux Esophagitis:

• Initiate or maximize high-dose PPI therapy to control ongoing inflammation, which is critical and often overlooked 1, 3
• PPI therapy after endoscopic dilation for peptic strictures reduces recurrence rates 1
• Use PPI rather than H2 receptor antagonists, which are ineffective in reducing repeat dilation needs 1

If Post-Ablation/Endotherapy Stricture:

• Offer PPI therapy after endoscopic resection or ablation to reduce stricture occurrence 1

Approach to Repeat Dilation

Repeat dilation is safe and effective when needed, with perforation rates no higher than other benign esophageal conditions 1:

• Endoscopic dilation can be performed safely using either balloon or bougie dilators based on clinician preference and stricture characteristics 1
• For EoE specifically, reassure patients that dilation is no more dangerous than for other esophageal diseases 1
• Inform patients that chest pain after dilation is common, particularly in EoE 1
• Symptom response after dilation typically lasts up to 1 year in EoE patients 1
• Repeat dilation sessions can be performed as needed when symptoms recur 1

Technical Considerations:

• Perform weekly or two-weekly dilation sessions until easy passage of ≥15 mm dilator is achieved along with symptomatic improvement 1
• For refractory strictures, use fluoroscopic guidance to improve safety and success 1, 3
• Consider intralesional steroid injections (triamcinolone 40 mg/mL, 0.5 mL aliquots to four quadrants) combined with dilation for refractory strictures with evidence of inflammation, as this has high-quality evidence for reducing repeat dilation frequency 1, 3

Post-Procedure Monitoring

• Monitor patients for at least 2 hours in recovery with clear written instructions on fluids, diet, and medications 1
• Ensure patients tolerate water before discharge 1
• Provide contact information for on-call team should chest pain, breathlessness, fever, or tachycardia develop 1
• Suspect perforation if persistent chest pain, breathlessness, fever, or tachycardia occurs—perform CT scan with oral contrast 1
• Routine imaging after uncomplicated procedures is not necessary 1

Common Pitfalls to Avoid

• Do not perform dilation alone without addressing underlying inflammation, as this does not treat the disease process and leads to recurrence 1
• Endoscopists frequently underestimate the presence of strictures and narrow lumen esophagus, particularly in EoE—maintain high index of suspicion 1
• For refractory strictures, ensure optimal management of ongoing inflammation with high-dose PPI before defining a stricture as truly refractory 1, 3
• Consider alternative neuromuscular causes (achalasia, esophageal dysmotility) in patients with ongoing dysphagia despite adequate esophageal diameter 1

Long-Term Management Strategy

• Maintenance anti-inflammatory therapy is essential, as clinical and histological relapse is high after withdrawal of topical steroid treatment 1
• For EoE patients refractory to treatment or with significant concomitant atopic disease, arrange joint management with gastroenterologist and specialist allergist 1
• Discuss the psychological impact of dietary therapy and chronic disease with patients and caregivers 1
• If PPI therapy causes unwanted side effects (diarrhea, GI infections, magnesium deficiency), switch to topical steroids or dietary therapy 1
• Monitor for Candida infection in patients on topical corticosteroids—manage with topical antifungals while continuing steroids 1