How should I manage an adult patient with Barrett's oesophagus, gastro‑oesophageal reflux disease and a refractory oesophageal stricture, particularly regarding acid suppression, definitive therapy, and the impact of the stricture on oral medication absorption?

Management of Barrett's Oesophagus with Refractory Stricture and GORD

Direct Answer

For an adult patient with Barrett's oesophagus, GORD, and a refractory oesophageal stricture, continue high-dose PPI therapy (twice-daily dosing), perform repeated endoscopic dilatation as needed, and consider fully covered self-expanding metal stents (SEMS) for truly refractory cases, while recognizing that the stricture itself does not significantly impair oral medication absorption in most cases. 1

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Acid Suppression Strategy

High-Dose PPI Therapy is Essential

• Prescribe twice-daily PPI therapy (e.g., omeprazole 20 mg twice daily, taken 30–60 minutes before meals) to maximize acid suppression and reduce stricture recurrence 1, 2
• PPI therapy after endoscopic resection or ablation reduces stricture occurrence in Barrett's oesophagus patients 1
• Continue long-term PPI maintenance therapy indefinitely in patients with documented erosive esophagitis or Barrett's oesophagus 2

Why PPIs Are Critical in This Context

• Acid suppression reduces the inflammatory stimulus driving stricture formation 1
• After dilatation, PPI therapy decreases the risk of stricture relapse 1
• The UK guidelines specifically recommend PPI therapy after endoscopic therapy or ablation for Barrett's oesophagus to prevent stricture development 1

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Definitive Management of Refractory Stricture

Repeated Endoscopic Dilatation

• Offer repeated dilatation as the primary intervention for symptomatic refractory strictures in Barrett's oesophagus patients 1
• Perforation rates for dilatation in post-endoscopic resection strictures can reach 1.1%, but this risk is acceptable given the benefit 1
• Repeat dilatation as needed when symptoms recur—there is no upper limit to the number of dilatation sessions 1

Advanced Options for Truly Refractory Cases

• Consider fully covered SEMS in carefully selected patients with refractory strictures that fail repeated dilatation 1

  • This is a weak recommendation with low-grade evidence, so reserve it for cases where conventional dilatation has clearly failed 1
  • SEMS placement carries its own risks (migration, perforation, pain) and should be performed by experienced endoscopists 1

• Consider steroid injection at the stricture site or oral prednisolone therapy to reduce recurrent stricture formation, particularly after large endoscopic resections 1

  • This is a weak recommendation with moderate evidence 1

When to Consider Surgical Intervention

• Antireflux surgery is NOT recommended as an antineoplastic measure in Barrett's oesophagus (Grade D recommendation) 1, 2
• Surgery may be considered only if:
  • The patient has persistent troublesome regurgitation despite optimal PPI therapy AND
  • Esophageal manometry confirms preserved peristaltic function AND
  • The patient accepts the trade-off of new post-surgical symptoms (dysphagia, flatulence, inability to belch) 1, 2, 3
• For severe or critical strictures unresponsive to all endoscopic measures, esophageal resection may be indicated, though this carries significant morbidity and mortality 4

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Impact of Stricture on Oral Medication Absorption

The Clinical Reality

Esophageal strictures do NOT significantly impair oral medication absorption in the vast majority of cases because:

• Medications that pass through the stricture (even if slowly) reach the stomach and are absorbed normally in the small intestine [@general medical knowledge@]
• The primary issue is mechanical obstruction causing dysphagia, not malabsorption 1

Practical Considerations

• Liquid or dissolvable formulations may be easier to swallow if the stricture causes significant dysphagia, but absorption remains intact once the medication reaches the stomach [@general medical knowledge@]
• Enteric-coated or sustained-release tablets may lodge at the stricture site and cause local mucosal injury (pill esophagitis), but this is a mechanical complication, not an absorption issue [@general medical knowledge@]
• If the stricture is so severe that the patient cannot swallow saliva (complete obstruction), urgent dilatation is required before any oral intake, including medications 1

When Absorption Might Be Compromised

• Only in cases of near-complete or complete obstruction where medications cannot physically pass through the stricture [@general medical knowledge@]
• In such cases, the patient will have food bolus obstruction and daily dysphagia, which are indications for urgent dilatation 1

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Algorithmic Approach to This Patient

Step 1: Optimize Acid Suppression

• Start or continue twice-daily PPI therapy (e.g., omeprazole 20 mg twice daily, 30–60 minutes before meals) 1, 2

Step 2: Perform Endoscopic Dilatation

• Offer dilatation for symptomatic stricture causing dysphagia or food impaction 1
• Inform the patient that perforation risk is approximately 1.1% 1
• Repeat dilatation as needed when symptoms recur 1

Step 3: If Stricture Remains Refractory After Multiple Dilatations

• Consider fully covered SEMS in carefully selected cases 1
• Consider steroid injection at the stricture site or oral prednisolone 1

Step 4: If All Endoscopic Measures Fail

• Refer to a multidisciplinary team (gastroenterology, thoracic surgery) to discuss esophageal resection for severe, life-limiting strictures 4
• Antireflux surgery alone is NOT appropriate for Barrett's oesophagus as an antineoplastic measure 1, 2

Step 5: Address Medication Absorption Concerns

• Reassure the patient that oral medication absorption is not significantly affected unless the stricture is near-complete [@general medical knowledge@]
• If dysphagia is severe, consider liquid formulations for ease of swallowing, but absorption will be normal once the medication reaches the stomach [@general medical knowledge@]

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Common Pitfalls and How to Avoid Them

Pitfall 1: Underestimating the Importance of PPI Therapy

• Avoid: Stopping or reducing PPI therapy after successful dilatation 1
• Correct approach: Continue twice-daily PPI indefinitely to reduce stricture recurrence 1, 2

Pitfall 2: Delaying Dilatation in Symptomatic Patients

• Avoid: Attempting prolonged medical therapy alone in patients with established tight strictures 1
• Correct approach: Offer dilatation promptly for symptomatic strictures, especially with food bolus obstruction or daily dysphagia 1

Pitfall 3: Overestimating the Impact on Medication Absorption

• Avoid: Switching to parenteral or enteral routes unnecessarily [@general medical knowledge@]
• Correct approach: Recognize that oral absorption is preserved unless the stricture is near-complete; focus on treating the stricture itself [@general medical knowledge@]

Pitfall 4: Considering Antireflux Surgery as a Cancer Prevention Strategy

• Avoid: Recommending fundoplication to prevent progression of Barrett's oesophagus to adenocarcinoma 1, 2
• Correct approach: Surgery is NOT indicated as an antineoplastic measure (Grade D recommendation) 1, 2

Pitfall 5: Giving Up After Initial Dilatation Failure

• Avoid: Labeling a stricture as "refractory" after only one or two dilatation attempts 1
• Correct approach: Repeat dilatation as many times as needed; symptom response after dilatation can last up to 1 year, and repeat procedures are safe 1

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Surveillance and Long-Term Management

Barrett's Oesophagus Surveillance

• Continue high-resolution white light endoscopy with Seattle biopsy protocol at intervals determined by the presence and grade of dysplasia 1
• The annual risk of adenocarcinoma in Barrett's oesophagus is approximately 0.5% per year 1, 2

Stricture Monitoring

• Repeat dilatation as needed based on symptom recurrence (dysphagia, food impaction) 1
• Inform patients that stricture recurrence is common and does not represent treatment failure 1