UpToDate - Esophageal Strictures, Dilation Flashcards
Most nonmalignant esophageal strictures result from what and are managed how?
GERD.
Managed w/ endoscopic dilation and medical therapy w/ acid suppression.
How do you classify esophageal strictures?
Simple or complex.
Simple - smooth, <2cm, straight, concentric, allow endoscope passage. Peptic strictures are usually simple.
Complex (any one) - >2cm, angulated, irregular, severely narrowed (<10 mm); assd w/ large hiatal hernia (5 cm), w/ esophageal diverticula, or TEF.
In terms of general intervention management, how would you manage a complex esophageal stricture differently than a simple one?
Guidewire-based system
How would you define a refractory esophageal stricture?
Unable to dilate to a diameter of 14mm over 5 endoscopic sessions (occurring at 2 week intervals).
Describe the patient with eosinophilic esophagitis.
Young patient with hx of food impaction.
What are contraindications for endoscopic interventions for nonmalignant esophageal strictures?
Can’t tolerate mod sedation/MAC/gen anesthesia.
Acute or incompletely healed esophageal perforation.
Disorders of hemostasis (plt 50K, INR 1.5).
HD instability.
Erosive esophagitis d/t uncontrolled GERD or recent food impactions. Defer intervention until underlying condition has been treated. and the mucosa has healed.
Eosinophilic esophagitis suspected but not confirmed/not treated.
How do you grade esophagitis?
LA classification - extent of mucosal abnormality, with complications recorded separately.
A - one or more mucosal breaks <5mm in length.
B - 1 or more break >5 mm, but not continuous b/w the tops of adj mucosal folds.
C - 1 or more break continuous b/w the tops of adj mucosal folds, but not circumferential.
D - mucosal break that involves at least three-fourths of the luminal circumference.
What are the goals of esophageal endoscopic nonmalignant stricture dilation?
Relief of dysphagia; reaching goal will be informed by patient symptoms.
In general, lumen diameter 18 mm (54 Fr) typically allows regular diet.
13 mm often allows thick liquid.
Describe patient preparation for esophageal dilation.
How many sizes should you increase by per session?
No need to hold ASA or NSAIDs.
No need for abx px.
3 sizes. Long (2 cm) or narrow (1 cm) should probably only be increased by 1 or 2 sizes.
What are you feeling for/looking for after each passage of a wire-guided push dilator (Savary) being used for non-malignant stricture dilation?
Minimal resistance and no blood on the dilator. If there is moderate resistance or blood, the dilation is complete.
What are some options for refractory nonmalignant strictures?
glucocorticoid injections
Glucocorticoid injection of refractory strictures resulted in lower risk of stricture recurrence and fewer dilation sessions. In a meta-analysis of six trials (most of which were nonblinded) including 176 patients with refractory esophageal strictures, triamcinolone injection plus endoscopic dilation resulted in lower risk of stricture recurrence (risk ratio 0.64, 95% CI 0.51-0.81) and fewer endoscopic dilation sessions (mean difference -1.06, 95% CI -1.80 to -0.31) compared with dilation alone.
Can you use steroid injections for anastomotic nonmalignant esophageal strictures?
Yes.
Data limited to patients with anastomotic strictures suggested that glucocorticoid injection reduced the total number of dilation sessions needed to achieve stricture resolution and resulted in lower risk of stricture recurrence.
Usually triamcinolone 10mg/ml into each of 4 quadrants of the stricture.
Manage eosinophilic esophagitis.
PPI or oral fluticasone vs budesonide.
Follow up w/ EGD.
Subsequent therapy includes elimination diet or dupilumab.
Dilation if non-interventional treatment fails.
