Management of Dysphagia from Esophageal Stricture in a Patient with Long-Standing Dyspepsia
The most appropriate management is endoscopic dilatation combined with high-dose proton pump inhibitor (PPI) therapy, with tissue diagnosis obtained prior to or during the procedure to exclude malignancy. 1
Initial Diagnostic Approach
Obtain tissue diagnosis before proceeding with dilatation unless the patient has absolute dysphagia (complete obstruction). 1 The stricture characteristics suggest a peptic etiology given the long-standing dyspepsia history, but malignancy must be excluded as it significantly alters both management and perforation risk estimation. 1
Pre-Dilatation Assessment
- Perform endoscopy with biopsies to document stricture location, length, mucosal appearance, and obtain histology. 1
- Consider barium swallow if the stricture is too tight to pass the endoscope, as this provides anatomical detail particularly helpful for long, tight, or complex strictures where dilatation carries greater technical difficulty and risk. 1
- Document features that increase perforation risk: stricture angulation, presence of diverticula, hiatus hernia, or small stomach. 1
Therapeutic Management
Endoscopic Dilatation
Perform graded dilatation to 13-20 mm diameter, which provides good symptomatic relief in 85-93% of peptic stricture cases. 1, 2 This should be undertaken as a planned procedure after appropriate investigation, preparation, and informed consent. 1
- Use either bougie or balloon dilators based on stricture characteristics (length, location, cause), as both are equally effective. 1
- Inform the patient of perforation risk (approximately 0.3-0.5% for benign strictures) and that operative intervention may be required if perforation occurs. 1
- Ensure 4-6 hours fasting prior to the procedure to ensure an empty esophagus and stomach. 1
Acid Suppression Therapy
Initiate high-dose PPI therapy immediately, as this is essential for healing coexistent esophagitis and reducing the need for repeat dilations. 1, 2, 3
- PPIs are superior to H2 receptor antagonists, which are ineffective in reducing stricture recurrence, less effective in healing esophagitis, and provide inferior symptom relief. 1
- Standard-dose PPI therapy reduces the need for repeat dilatation compared to no acid suppression. 1
- Consider twice-daily PPI dosing if restenosis occurs rapidly despite standard dosing. 1
Management of Refractory Strictures
If the patient requires frequent repeat dilations despite maximal PPI therapy:
- Weekly dilatation until easy passage of >14 mm dilator is a common strategy for tight strictures requiring short-interval redilatation. 1
- Consider intralesional steroid injection (0.5 mL aliquots of 40 mg/mL triamcinolone in four quadrants) combined with dilatation if there is evidence of inflammation and anti-reflux therapy has been maximized. 1
- Consider temporary placement of fully covered self-expanding metal stents (4-8 weeks) if previous methods fail to maintain adequate patency, though migration occurs in ~30% and adverse events in ~20%. 1
- Refer for anti-reflux surgery if frequent dilations are needed despite PPI therapy or if technically difficult to dilate. 1
Critical Pitfalls to Avoid
- Do not dilate without tissue diagnosis when stricture appearance suggests malignancy or when the stricture is tight, as malignant strictures have higher perforation rates. 1
- Do not use H2 receptor antagonists as they are ineffective for stricture management. 1
- Do not assume the stricture is the sole problem if refractory to dilatation—consider alternative neuromuscular causes like achalasia or esophageal spasm. 2
- Obtain further biopsies and imaging if restenosis occurs rapidly despite adequate PPI therapy, as this may indicate occult malignancy. 1
Post-Procedure Monitoring
Observe the patient closely after dilatation—uncomplicated cases may be managed as outpatients. 1 Perform urgent chest x-ray and contrast study if the patient develops pain, breathlessness, fever, or tachycardia, as these suggest perforation. 1