What is the next step in management for an adult female with a history of unintentional corrosive ingestion, resulting in severe esophageal strictures, who has undergone regular dilatation for 3 months with a feeding jejunostomy (jejunum ostomy)?

From the Guidelines

The first step in managing this adult female patient with severe esophageal strictures due to corrosive ingestion who has been undergoing regular dilatation for 3 months with feeding jejunostomy would be to continue endoscopic dilatation (option A). Before considering more invasive options, it's essential to continue with the current dilatation therapy as it often requires multiple sessions over an extended period to achieve optimal results, with the goal of achieving easy passage of a ≥15 mm dilator along with symptomatic improvement 1. During this management, ensure proper ABCDE assessment (Airway, Breathing, Circulation, Disability, Exposure) at each visit, followed by appropriate pain management with analgesics like acetaminophen or NSAIDs. Antibiotics should be considered only if there are signs of infection, and short-course corticosteroids may help reduce post-dilatation inflammation. The safety of endoscopic dilatation has been established, with a low risk of perforation, similar to other benign conditions, and it is equally effective and safe in adults and children 1. If after an extended period of regular dilatation the patient shows no improvement or experiences recurrent strictures despite adequate therapy, then alternative approaches such as stent placement, esophageal bypass, or resection might be considered.

Some key points to consider in the management of this patient include:

• The importance of regular and systematic dilatation sessions to achieve optimal results, with the frequency of sessions determined by the patient's response to the procedure and the degree of stricture resolution 1.
• The need for careful assessment and management of potential complications, such as pain, infection, and perforation, during and after dilatation procedures 1.
• The consideration of alternative approaches, such as stent placement, esophageal bypass, or resection, if the patient does not respond to dilatation therapy or experiences recurrent strictures despite adequate treatment.

Overall, continuing dilatation is justified as it is the least invasive option with good success rates when performed regularly and systematically, allowing the patient to potentially avoid major surgery while maintaining nutritional support through the existing jejunostomy.

From the Research

Next Steps for the Patient

The patient has a history of unintentional corrosive ingestion, which led to severe oesophageal strictures. She has been undergoing regular dilatation for 3 months with feeding jejunostomy. Considering her current situation, the next steps for her management can be outlined as follows:

• Continuation of Endoscopic Dilatation: The study by 2 suggests that endoscopic dilatation is safe and effective for short and long term relief of dysphagia in patients with corrosive oesophageal strictures. Therefore, continuing endoscopic dilatation (Option A) seems to be a viable option for her.
• Alternative Options: Other options such as oesophageal resection (Option B), stent placement (Option C), and oesophageal bypass (Option D) may be considered if the patient's condition does not improve with dilatation or if she experiences complications.
• Scheduled Dilatation Program: The study by 3 suggests that a scheduled program of repeated and sustained esophageal dilations can lead to a higher probability of final success and lower treatment duration. This approach may be beneficial for the patient.

Key Considerations

When deciding on the next steps for the patient's management, the following factors should be considered:

• The patient's response to previous dilatation treatments
• The severity of her oesophageal strictures
• The presence of any complications or adverse effects from previous treatments
• The patient's overall health and well-being

Management Options

The following management options are available for the patient:

• Endoscopic Dilatation: This is a minimally invasive procedure that can be used to widen the oesophageal lumen and relieve dysphagia.
• Oesophageal Resection: This is a surgical procedure that involves removing the affected portion of the oesophagus and reconnecting the remaining portions.
• Stent Placement: This involves placing a metal or plastic stent in the oesophagus to keep it open and allow for normal swallowing.
• Oesophageal Bypass: This is a surgical procedure that involves creating a new pathway for food to bypass the affected portion of the oesophagus.