What is the best course of treatment for an adult patient with a history of Gastroesophageal Reflux Disease (GERD) presenting with esophageal stricture symptoms, including dysphagia?

Treatment of GERD-Related Esophageal Stricture with Dysphagia

For an adult patient with GERD presenting with esophageal stricture and dysphagia, initiate high-dose proton pump inhibitor (PPI) therapy immediately and perform endoscopic dilation to achieve a target diameter of ≥15 mm, followed by long-term PPI maintenance to prevent stricture recurrence. 1

Initial Diagnostic Approach

Before proceeding with treatment, confirm the diagnosis and exclude malignancy:

• Perform upper endoscopy with biopsies to rule out malignant stricture, as this is essential before any therapeutic intervention 1, 2
• Consider barium esophagram to define stricture length, diameter, and complexity 2, 3
• Recognize that dysphagia may result from active esophagitis rather than the stricture itself, and symptoms can improve with PPI therapy alone in some cases 1

Primary Treatment Strategy

Step 1: Initiate PPI Therapy

Start high-dose PPI therapy (omeprazole 40 mg once daily or equivalent) before dilation when possible, as healing the coexistent esophagitis is essential and may reduce dysphagia without requiring immediate dilation 1, 4

• PPIs are superior to H2 receptor antagonists, which are ineffective in reducing the need for repeat dilation 1
• Take PPIs 30-60 minutes before meals for optimal efficacy 1, 5
• If symptoms persist after 4-8 weeks of PPI therapy, proceed with endoscopic dilation 1

Step 2: Endoscopic Dilation

Perform endoscopic dilation using either through-the-scope balloons or wire-guided bougies to relieve dysphagia 1, 6

• Schedule repeat dilation sessions every 1-2 weeks until achieving a target diameter of ≥15 mm with symptomatic improvement 1, 6
• Between 40-60% of peptic strictures require only one dilation, with the need for redilatation highest in the subsequent 1-2 years 1
• Patients with smaller stricture diameter and longer strictures are less likely to respond and may require multiple sessions 1

Use fluoroscopic guidance for complex strictures (post-radiation, caustic, long, angulated, or multiple strictures) 1, 6

Step 3: Long-Term PPI Maintenance

Continue high-dose PPI therapy (omeprazole 20-40 mg once daily) indefinitely after dilation to reduce stricture recurrence and maintain healing 1, 5

• PPI therapy after dilation significantly reduces the recurrence rate of peptic strictures (high-quality evidence, strong recommendation) 1
• This is more effective than H2 receptor antagonists in preventing relapse 1

Management of Refractory Strictures

If the stricture recurs despite optimal PPI therapy and requires ≥5 dilation sessions at 1-2 week intervals without maintaining a diameter ≥14 mm, consider it refractory 6:

• Inject intralesional corticosteroids (triamcinolone 40 mg/mL in 0.5 mL aliquots to four quadrants) immediately before dilation 1, 4, 2
• Consider temporary placement of fully covered self-expanding metal stents for 4-8 weeks 1, 2
• Surgical intervention (fundoplication) is reserved for patients with intractable esophagitis, irreversibly damaged esophagus, or extraesophageal manifestations 7, 8

Post-Procedure Monitoring

• Monitor patients for at least 2 hours after dilation before discharge 1
• Provide contact information for the on-call team in case of complications 1
• Ensure patients can tolerate water before leaving 6
• Consider (but do not mandate) water-soluble contrast swallow to screen for perforation if clinically indicated 1

Critical Safety Considerations

Suspect perforation if patients develop chest pain, dyspnea, fever, or tachycardia after dilation and obtain immediate imaging 6

The perforation rate for peptic stricture dilation is low when performed carefully, but vigilance is essential 1

Important Caveats

Rule Out Eosinophilic Esophagitis

If the patient is younger, has food bolus obstruction, or symptoms are unresponsive to PPI therapy, obtain esophageal biopsies from proximal, mid, and distal esophagus to exclude eosinophilic esophagitis, which requires different management 1

• EoE symptoms are typically unresponsive or only partially responsive to acid blockade 1
• EoE strictures require disease-modifying therapy (topical steroids or dietary elimination) in addition to dilation 1

Avoid Common Pitfalls

• Do not rely solely on dilation without addressing the underlying acid reflux with PPIs, as this leads to rapid recurrence 1, 4
• Do not use H2 receptor antagonists as they are ineffective for stricture prevention 1
• Do not perform dilation on asymptomatic strictures discovered incidentally 1
• Recognize that healing of active esophagitis contributes significantly to symptom improvement and reduces the need for repeat dilation 1