From the Guidelines
For an adult girl with a history of unintentional corrosive ingestion resulting in severe esophageal strictures who has been undergoing regular dilatation for 3 months with feeding jejunostomy, the next appropriate step would be to continue endoscopic dilatation. This approach is supported by the UK guidelines on oesophageal dilatation in clinical practice, which emphasize the role of dilatation in treating symptomatic narrowing of the oesophagus, including corrosive strictures 1. The primary aim of oesophageal dilatation is to alleviate symptoms, permit maintenance of oral nutrition, and reduce the risk of pulmonary aspiration. Given that the patient has only been undergoing dilatation for 3 months, it is reasonable to continue this treatment, as it may take several months to a year or more to achieve optimal results.
Some key points to consider in the management of this patient include:
- The importance of a team approach involving endoscopists and radiologists in deciding the best course of treatment for esophageal strictures 1.
- The need for repeated dilatations over time, as the formation of strictures is a dynamic process that can recur after initial treatment.
- The role of feeding jejunostomy in maintaining nutrition while the patient undergoes dilatation therapy, which is crucial for overall health and recovery.
- The potential for complications, such as perforation, which would necessitate a reevaluation of the treatment plan and possible consideration of more invasive interventions like esophageal resection or stent placement.
Continuing endoscopic dilatation as the first-line management for this patient's esophageal strictures is the most appropriate next step, given its less invasive nature and potential for effectiveness in maintaining esophageal patency, as outlined in the guidelines 1. More aggressive interventions should be reserved for cases where dilatation fails or complications arise, prioritizing the patient's morbidity, mortality, and quality of life.
From the Research
Next Steps for the Patient
The patient has been undergoing regular dilatation for 3 months with feeding jejunostomy following severe oesophageal strictures due to unintentional corrosive ingestion. Considering the provided evidence, the next steps for the patient can be outlined as follows:
- Continue Endoscopic Dilatation: The studies 2, 3, 4, 5, 6 suggest that endoscopic dilatation is a safe and effective treatment for benign esophageal strictures, including those caused by corrosive ingestion.
- Consider Alternative Endoscopic Treatments: If the patient experiences refractory or recurrent strictures, alternative endoscopic treatments such as steroid injection, incisional therapy, or stent placement may be considered, as mentioned in the studies 2, 5.
- Surgical Intervention: Surgery, including oesophageal resection or bypass, may be considered only if endoscopic dilatation fails, as stated in the study 3.
Key Considerations
- The patient's response to ongoing dilatation and feeding jejunostomy should be closely monitored.
- The risk of complications, such as perforation, should be considered when performing endoscopic dilatation, as noted in the study 4.
- The patient's overall health and nutritional status should be taken into account when determining the best course of treatment.
Treatment Options
- Endoscopic Dilatation: This is the recommended primary therapy for chronic corrosive esophageal strictures, as stated in the study 3.
- Stent Placement: This may be considered for patients with refractory or recurrent strictures, as mentioned in the study 2.
- Oesophageal Resection or Bypass: These surgical options may be considered only if endoscopic dilatation fails, as stated in the study 3.