AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
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• Workup
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
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Background

Disease processes that can produce esophageal strictures can be grouped into 3 general categories: (1) intrinsic diseases that narrow the esophageal lumen through inflammation, fibrosis, or neoplasia; (2) extrinsic diseases that compromise the esophageal lumen by direct invasion or lymph node enlargement; and (3) diseases that disrupt esophageal peristalsis and/or lower esophageal sphincter (LES) function by their effects on esophageal smooth muscle and its innervation.

Many diseases can cause esophageal stricture formation. These include acid peptic, autoimmune, infectious, caustic, congenital, iatrogenic, medication-induced, radiation-induced, malignant, and idiopathic disease processes.

The etiology of esophageal stricture can usually be identified using radiologic and endoscopic modalities and can be confirmed by endoscopic visualization and tissue biopsy. Use of manometry can be diagnostic when dysmotility is suspected as the primary process. CT scan and endoscopic ultrasound are valuable aids in the staging of malignant stricture. Fortunately, most benign esophageal strictures are amenable to pharmacological, endoscopic, and/or surgical interventions.

Because peptic strictures account for 70-80% of all cases of esophageal stricture, peptic stricture is the focus of this article. A detailed discussion of possible benign and malignant processes associated with esophageal stricture and its management is beyond the scope of this article.

Pathophysiology

Peptic strictures are sequelae of gastroesophageal reflux–induced esophagitis, and they usually originate from the squamocolumnar junction and average 1-4 cm in length.

• Two major factors involved in the development of a peptic stricture are as follows:
• • Dysfunctional lower esophageal sphincter: Mean LES pressures are lower in patients with peptic strictures compared with healthy controls or patients with milder degrees of reflux disease. A study by Ahtaridis et al (1979) showed that patients with peptic strictures had a mean LES pressure of 4.9 mm Hg versus 20 mm Hg in control patients. LES pressure of less than 8 mm Hg appeared to correlate significantly with the presence of peptic esophageal stricture without any overlap in controls.
  • Disordered motility resulting in poor esophageal clearance: In the same study, Ahtaridis et al (1979) demonstrated that 64% of patients with strictures had motility disorders compared with 32% of patients without strictures.
• Other possible associated factors include the following:
• • Presence of a hiatal hernia: Hiatal hernias are found in 10-15% of the general population, 42% of patients with reflux symptoms and no esophagitis, 63% of patients with esophagitis, and 85% of patients with peptic strictures. This suggests that hiatal hernias may play a significant role.
  • Acid and pepsin secretion: This does not appear to be a major factor. Patients with peptic strictures have been demonstrated to have the same acid and pepsin secretion rates as gender-matched and age-matched controls with esophagitis but no stricture formation. In fact, some authors believe that alkaline reflux may play an important role.
  • Gastric emptying: No good evidence suggests that delayed emptying plays a role.

Frequency

United States

Gastroesophageal reflux affects approximately 40% of adults. Strictures are estimated to occur in 7-23% of untreated patients with reflux disease.

Gastroesophageal reflux disease accounts for approximately 70-80% of all cases of esophageal stricture. Postoperative strictures account for about 10%, and corrosive strictures account for less than 5%.

The overall frequency of initial and subsequent dilations for peptic stricture appears to have decreased gradually since the introduction of proton pump inhibitors (PPIs) in the market in 1989. This has been borne out by data at the author's institution and in 2 large community hospitals in Wisconsin. It is also in keeping with the general experience of gastroenterologists in the United States.

Mortality/Morbidity

The mortality rate is not increased unless a procedure-related perforation occurs or the stricture is malignant. However, the morbidity for peptic strictures is significant.

• Most patients undergo a chronic relapsing course with an increased risk of food impaction and pulmonary aspiration.
• Frequently, coexistent Barrett esophagus and its attendant complications occur.
• The need for repeated dilatation potentially increases the risk of perforation.

Race

Peptic strictures are 10-fold more common in whites than African Americans or Asians.

Sex

Peptic strictures are 2- to 3-fold more common in men than in women.

Age

Patients tend to be older, with a longer duration of reflux symptoms.

CLINICAL

Section 3 of 11  

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History

• Patients may present with heartburn, dysphagia, odynophagia, food impaction, weight loss, and chest pain.
• Progressive dysphagia for solids is the most common presenting symptom. This may progress to include liquids.
• Atypical presentations include chronic cough and asthma secondary to aspiration of food or acid.
• The clinician cannot rely on the presence or absence of heartburn to definitely determine whether dysphagia is secondary to a peptic esophageal stricture.
• • Of patients with peptic esophageal strictures, 25% have no previous history of heartburn.
  • Heartburn may resolve with worsening of a peptic stricture.
  • Approximately two thirds of patients with adenocarcinoma in Barrett esophagus have a history of long-standing heartburn.
  • The abnormal esophageal motor activity in achalasia can produce a heartburn sensation.
• Important points regarding dysphagia
• • The obstruction usually is perceived at a point that is either above or at the level of the lesion.
  • Dysphagia for solids and liquids simultaneously should alert the clinician to the possibility of a motility disorder such as achalasia or collagen vascular disorders.
  • Dysphagia secondary to Schatzki ring usually is intermittent and nonprogressive.
  • Dysphagia for solids and liquids early in the course of disease should alert the clinician to the possibility of achalasia as an etiology.
  • Benign esophageal strictures usually produce dysphagia with slow and insidious progression (ie, months to years) of frequency and severity with minimal weight loss.
  • Malignant esophageal strictures result in a rapid progression (ie, weeks to months) of severity and frequency of dysphagia and are associated frequently with significant weight loss.
• Determining whether the patient takes any medications known to cause pill esophagitis is important.
• Determining whether a history of collagen vascular disease or immunosuppression exists may provide clues to the underlying etiology.

Physical

• Physical examination frequently does not provide clues to the cause of dysphagia.
• Assessing the patient's nutritional status is important.
• Patients with collagen vascular diseases may exhibit joint abnormalities, calcinosis, telangiectasias, sclerodactyly, or rashes.
• The presence of atypical gastroesophageal reflux disease may be suggested by hoarse voice, posterior oropharyngeal erythema, diffuse dental erosions, wheezing, or epigastric tenderness.
• Patients with adenocarcinoma of the gastroesophageal junction may have left supraclavicular lymphadenopathy (Virchow node).

Causes

• Proximal or mid esophageal strictures
• • Caustic ingestion (acid or alkali)
  • Malignancy
  • Radiation therapy
  • Infectious esophagitis - Candida, herpes simplex virus (HSV), cytomegalovirus (CMV), HIV
  • AIDS and immunosuppression in patients who have received a transplant
  • Medication-induced stricture (pill esophagitis) - Alendronate, ferrous sulfate, nonsteroidal anti-inflammatory drugs, phenytoin, potassium chloride, quinidine, tetracycline, ascorbic acid
  • Diseases of the skin - Pemphigus vulgaris, benign mucous membrane (cicatricial) pemphigoid, epidermolysis bullosa dystrophica
  • Graft versus host disease
  • Idiopathic eosinophilic esophagitis
  • Extrinsic compression
  • Squamous cell carcinoma
  • Miscellaneous - Trauma to the esophagus from external forces, foreign body, surgical anastomosis/postoperative stricture, congenital esophageal stenosis
• Distal esophageal strictures
• • Peptic stricture - Gastroesophageal reflux disease, Zollinger-Ellison syndrome
  • Adenocarcinoma
  • Collagen vascular disease - Scleroderma, systemic lupus erythematosus (SLE), rheumatoid arthritis
  • Extrinsic compression
  • Alkaline reflux following gastric resection
  • Sclerotherapy and prolonged nasogastric intubation
  • Crohn disease

DIFFERENTIALS

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Other Problems to be Considered

Esophageal malignancy

WORKUP

Section 5 of 11  

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Lab Studies

• CBC: Usually, the results on CBC are within the reference range; however, anemia may develop due to chronic bleeding from severe esophagitis or carcinoma.
• Liver profile: Usually, the findings are within the reference range; however, the findings may be abnormal if metastatic disease in underlying malignancy is present.
• Complete metabolic panel: This may allow assessment of the nutritional status, especially in conjunction with weight loss.

Imaging Studies

• Barium esophagram
• • Barium esophagram provides an objective baseline record of the esophagus prior to medical therapy or endoscopic intervention.
  • This study also provides information about the location, length, and diameter of the stricture and the smoothness or irregularity of the esophageal wall (road map).
  • The information obtained can complement endoscopic findings.
  • Lesions, such as diverticula and paraesophageal hernias, that potentially may lead to increased risk of complications during endoscopy can be identified.
  • This study may be more sensitive than endoscopy for detection of subtle narrowings of the esophagus such as those caused by rings and peptic strictures that are greater than 10 mm in diameter.
  • This study has 100% sensitivity with luminal diameter less than 9 mm, and 90% sensitivity with luminal diameter greater than 10 mm.
• Chest radiograph, posteroanterior (PA) and lateral: Chest radiography should be used as an adjunct if extrinsic compression is considered a possible etiology of esophageal stricture.
• Computed tomography scan
• • CT scan can be used to stage malignancies that produce esophageal strictures.
  • Accuracy in estimating the depth of tumor invasion is 60-69%.
  • Accuracy in determining spread to other organs is 82%.
• Endoscopic ultrasound
• • Endoscopic ultrasound (EUS) is the most accurate means of identifying the extent of local invasion of an esophageal malignancy.
  • Accuracy in estimating the depth of tumor invasion in the esophagus is 92%.

Other Tests

• Twenty-four–hour esophageal pH monitoring: This may be helpful in evaluating and documenting the adequacy of therapy in patients who remain symptomatic despite treatment with PPIs or fundoplication.
• Esophageal manometry
• • This test is used to evaluate any patient suspected of having esophageal dysmotility.
  • It may be used as a preoperative tool prior to antireflux surgery to evaluate the presence of severe esophageal dysmotility.

Procedures

• Esophagogastroduodenoscopy
• • This procedure can be used to establish or confirm the diagnosis, to seek evidence of esophagitis, to exclude malignancy, to obtain biopsy and brush cytology specimens, and to implement therapy.
  • It is more sensitive than barium esophagram in the identification of subtle mucosal lesions.
  • Subtle strictures may be missed when smaller and thinner endoscopes are employed, especially in the setting of minimal sedation.

Histologic Findings

Initial histologic changes in the peptic stricture process include edema, cellular infiltration, basal cell hyperplasia, and vascular changes with a slight increase in type III collagen deposition on healing.

If untreated, the process can lead to progressive inflammation and ulceration involving the submucosa and muscularis mucosa. This can lead to damage of the muscular layer and the intrinsic nervous system of the esophagus, resulting in deposition of type I collagen with subsequent formation of scar tissue and stricture formation.

Staging

CT scan and EUS are used mainly to stage malignancies that produce esophageal strictures.

• CT scan - Sixty to 69% accurate in estimating the depth of tumor invasion and 82% accurate in determining spread to other organs
• EUS - Most accurate means of identifying the extent of local invasion and 92% accurate in estimating the depth of tumor invasion in the esophagus

TREATMENT

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Medical Care

Traditionally, more emphasis has been placed on mechanical dilatation, and coexistent esophagitis has been relatively ignored. However, several studies have demonstrated that aggressive acid suppression using PPIs is extremely beneficial in the initial treatment, as well as long-term management.

• A dysphagia score developed by Dakkak et al (1993) in a study of 64 patients revealed that the stricture diameter only contributed to 30% of the dysphagia score and that esophagitis and other factors accounted for 70% of the score. A linear association existed between the dysphagia score only when the luminal diameter was less than 5 mm. Overall, the degree of dysphagia was worse with increasing esophagitis independent of the degree of stenosis.
• Smith et al (1994) showed in a randomized study of 366 patients that omeprazole 20 mg/d was superior to ranitidine 300 mg twice a day in preventing stricture recurrence with redilation rates of 30% and 46% respectively at 12 months (P <0.01).
• Marks et al (1994) showed that the redilation rate in patients treated with omeprazole 20-40 mg/d was 41% versus 73% in patients treated with ranitidine 150-300 mg twice per day and almost reached significance (P <0.07). However, the omeprazole group showed higher rates of dysphagia relief and healing of esophagitis when compared with histamine 2 (H2) blockers.
• In contrast, 2 other studies by Swarbrick et al (1998) and Silvis et al (1996) did not show any significant differences in the redilation rates at 12 and 10 months, respectively.
• PPI treatment of patients with esophageal stricture also is more cost effective than H2 blocker therapy. Marks et al (1994) found that over a 6-month period the cost of omeprazole therapy was $1744 compared with $2957 with H2 blockers.
• H2 blockers have not been shown to be any better than placebo in various trials, and no reliable data on prokinetic agents exist.

Surgical Care

The following discussion concerns the endoscopic and surgical modalities employed for the management of peptic esophageal stricture. The choice of dilator and technique is dependent on many factors, the most important being stricture characteristics. It also is based on other factors, including patient tolerance, operator preference, and experience. No clear consensus on the optimal endpoint exists. In summary, dilatation therapy should be tailored individually.

• Endoscopic dilation dates to the 16th century, when physicians used wax wands for esophageal dilation. The word bougie is derived from Boujiyah, an Algerian city that was the center of the medieval candle trade. The following 3 types of dilators are used:
• • Mercury-filled bougies - Maloney or Hurst dilators
  • • These dilators are indicated in uncomplicated strictures with diameters greater than 10-12 mm.
    • They are inexpensive and simple to perform without fluoroscopic guidance.
    • Minimal or no sedation is necessary.
    • Self-bougienage may be performed at home.
  • Wire-guided polyvinyl bougies - Savary-Gilliard and American dilators
  • • These dilators are relatively stiff and better suited to longer, tighter, and irregular strictures.
    • The need for fluoroscopy is variable.
    • The range is 5-20 mm, and these dilators are reusable.
    • Drawbacks include trauma to the laryngeal wall and patient discomfort.
    • American dilators are shorter, less tapered, and impregnated with barium for better fluoroscopic visualization.
  • Through-the-scope (TTS) balloon dilators
  • • These dilators are used through the endoscope, and they allow for direct visualization.
    • These are relatively expensive and not reusable.
    • Fluoroscopy is not mandatory, but it is useful in difficult cases.
    • Studies conflict about the benefits of balloon dilators compared to Savary dilators.
• A prospective, randomized study with 17 patients in each arm comparing balloon dilators with Savary dilators was performed by Saeed et al (1995) over a 2-year period, with the endpoint being 45F.
• • Stricture recurrence was similar in the first year but lower in the second year for balloons.
  • Fewer sessions were needed for balloons, 1.1 sessions plus or minus 0.1 versus 1.7 sessions plus or minus 0.2, and less procedural discomfort occurred (P <0.05).
  • Both devices were effective in relieving dysphagia.
• Another prospective, randomized study by Scolapio et al (1999) included 251 patients with peptic strictures. Schatzki rings did not show any differences in complications, the degree of immediate relief, or the time to recurrent dysphagia.
• General rules of esophageal dilation
• • Many authors have questioned the need for mandatory fluoroscopy, and no published data exist to advocate safety of fluoroscopy. However, one may consider using fluoroscopy in complicated strictures, especially in guiding the blind passage of a guidewire.
  • Rule of 3s: The first bougie passed should be approximately equal to the estimated diameter of the stricture. Pass no more than 3 consecutive bougies of progressively increasing size after the first one that meets moderate resistance during any one dilation session. The rule of 3s has been questioned because of a lack of data verifying the increased efficacy or safety if one adheres to this rule. This rule was formulated for dilation using mercury-filled bougies resulting in dilation no greater than 1.3 mm in one session. However, polyvinyl dilators may not provide adequate tactile perception to follow this rule.
  • A study by Kozarek et al (1995) showed only one perforation in 400 patients dilated with polyvinyl dilators to greater than 2 mm in one session.
  • Balloon dilators frequently dilate greater than that prescribed by the rule of 3s without any increased risk of complications.
• No consensus exists regarding the endpoint of esophageal dilatation for peptic strictures.
• • Most patients experience complete relief when dilated to 40-54F. Therefore, using this endpoint as a benchmark is recommended.
  • In summary, the extent of dilatation should be individualized based on symptomatic response and technical difficulty encountered during therapy.
• Intralesional steroid injection
• • Limited anecdotal data exist showing that intralesional steroid injection of peptic strictures may be beneficial. The mechanism is unclear; it may inhibit collagen formation and enhance collagen degradation, thus increasing stricture compliance.
  • Triamcinolone 10 mg/mL in 0.5 mL aliquots was injected in 4 quadrants in 2 patients with a successful outcome as reported by Kirsch et al (1991).
  • Lee at al (1995) showed a higher rate of achieving greater luminal diameters and duration between dilations in a nonrandomized cohort of patients with strictures of varying etiologies. Similar results were obtained by Kochhar et al (2002) in 71 patients, although 8 injections of 20 mg of triamcinolone in 0.5-mL aliquots were given at the proximal margin and into the stricture itself.
  • A randomized prospective trial of Savary dilation with or without intralesional steroids was conducted in 42 patients by Dunne et al (1999); it demonstrated a decreased need for second dilations in the steroid group (1.95 vs 5.5) at 1 year. Similar results were seen in a study by Ramage et al (2005) in 30 patients, but the latter study was also double blinded with a sham group. Two patients (13%) in the steroid group and 9 patients (60%) in the sham group needed repeat dilation over a 12-month period.
  • Therefore, a trial of steroid injection may be reasonable in patients with benign strictures who experience no significant relief of dysphagia despite repeated dilations and aggressive antireflux therapy.
• Endoscopic stricturoplasty: Two case series describe a technique using a needle knife to make 4 quadrant incisions followed by Savary dilation. This was successful in 8 out of 8 patients as reported by Raijman et al (1999) and 5 out of 6 patients as reported by Hagiwara et al (1999).
• Expandable polyester silicone-covered stent: Repici et al (2004) presented a case series of 15 patients who had failed endoscopic therapy. A temporary placement of a stent for 6 weeks was successful in 12 patients over a long-term period (mean follow-up, 22.7 [2.6] mo). One stent migrated into the stomach.
• The role of surgical treatment in peptic stricture remains in dispute. Indications include failed aggressive medical therapy or an unsuitable candidate for aggressive medical therapy. This usually is a rare occurrence in the era of PPI therapy. Various procedures advocated include the following:
• • Esophageal-sparing procedures - Standard antireflux surgery (Nissen total or Belsey partial fundoplication), esophageal lengthening with antireflux surgery (Collis-Nissen or Belsey gastroplasty)
  • Esophageal resection and reconstruction - Gastric or colon interposition or jejunal segment
• If the benign peptic stricture is dilatable, an esophageal-sparing operation is performed.
• • If the length of the esophagus is normal, standard antireflux surgery and postoperative dilation as necessary is recommended.
  • If the esophagus is short, performing Collis gastroplasty and postoperative dilation as necessary is recommended.
  • If the stricture is undilatable, esophageal resection and interposition is recommended.
• In the literature, some anecdotal reports exist of minimally invasive surgery, including laparoscopic transhiatal esophagectomy and laparoscopic Collis gastroplasty with Nissen fundoplication. With continuing advances in technology, whether minimally invasive surgery would play a major role in the surgical management of peptic stricture remains to be determined.

Consultations

• Surgical consultation is indicated if aggressive medical therapy fails or the patient is an unsuitable candidate for aggressive medical therapy.
• Surgical consultation also is indicated if the stricture is malignant and amenable to curative or palliative resection.

Diet

The usual antireflux precautions and lifestyle modifications should be reinforced, although no published data exist showing that these measures are efficacious in peptic strictures.

• Patients are told to avoid fatty and spicy foods, alcohol, tobacco, chocolate, and peppermint.
• Patients should eat smaller meals, avoid eating in a hurried fashion, and chew their food well.
• Patients should be encouraged not to eat at least 2-3 hours before bedtime.
• Weight reduction should be encouraged.
• Ill-fitting dentures or poor dentition should be corrected if possible.

Activity

No specific limitation in activity exists.

MEDICATION

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Antisecretory medications generally are used for the treatment of acid-peptic stricture of the esophagus. PPIs are the most efficacious drugs, and usually the class is used routinely.

Drug Category: Proton pump inhibitors

Specifically inhibit the H⁺/K⁺-ATPase enzyme system at the secretory surface of the gastric parietal cell, resulting in a potent antisecretory effect.

FOLLOW-UP

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Further Outpatient Care

• Closely follow patients' cases to determine the adequacy of esophageal dilation or surgery in relieving dysphagia and the adequacy of pharmacological antireflux therapy.
• Individualize the interval of follow-up visits.
• Recurrent dysphagia or inadequate reflux symptom relief should prompt repeat dilation and more aggressive antireflux therapy as necessary.
• Counsel patients on an ongoing basis regarding the benefits of antireflux dietary precautions and lifestyle modifications.

In/Out Patient Meds

• Long-term PPI therapy (almost indefinitely) is extremely important.
• The dosage of PPIs may be guided by the patient response and based on endoscopic findings on repeat endoscopies and dilatation.
• Not unusually, these patients require high-dose PPI therapy to achieve the most satisfactory response.

Deterrence/Prevention

• Several studies have shown that aggressive acid suppression using PPIs is extremely beneficial in the long-term management of peptic strictures in terms of stricture recurrence (see Medical Care).
• Patients must continue to follow antireflux precautions and modify their lifestyle as necessary to complement medical therapy.
• Reviewing all prescription and over-the-counter medications on a regular basis is important to prevent medication-induced stricture recurrence or worsening.
• Educate all patients about not taking medications known to cause esophagitis, including over-the-counter medications such as aspirin and nonsteroidal anti-inflammatory drugs.
• Two recent studies have shown that the number of stricture dilatations has decreased dramatically in North America since the introduction of PPIs in the market.
• In a study by Dunne et al (1997), the annual number of dilatations decreased from approximately 120 in the pre-PPI era to 50 in the post-PPI era in Kingston, Ontario.
• In another study by Ugheoke et al in the United States, the number of dilatations performed in 4-year intervals decreased from 504 in the pre-PPI era to 144 in the post-PPI era in one institution.
• Computerized databases from 1986-2001 of 2 large community hospitals were analyzed by Guda et al (2004). The need for stricture dilation peaked in 1994 but dropped significantly from 1998-2001, corresponding to an increase in the use of proton pump inhibitors from 1995 onward.

Complications

• Perforation
• Bleeding
• • A 1974 American Society of Gastrointestinal Endoscopy (ASGE) survey estimated rates of perforation and bleeding to be 0.1% and 0.3%, respectively.
  • A 1984 ASGE survey estimated the overall complication rate to be 2.5%.
  • In general, both of these complications seem to occur with equal frequency, but significant variation in published reports exists.
  • Providing precise estimates is difficult because of flawed methodologies in the published literature. However, based on this review, one would estimate that the risk of serious complications is approximately 0.5%.
• Bacteremia
• • Bacteremia appears to occur in approximately 20-45% of all dilations based on some reports in the literature; however, it usually is clinically insignificant, and reports of endocarditis and brain abscesses are rare.
  • Antibiotic prophylaxis is recommended in all high-risk cases as defined by the American Heart Association guidelines.

Prognosis

• Esophageal dilation
• • Several studies have shown that progressive dilation of peptic strictures to 40-60F resulted in effective relief of dysphagia in approximately 85% of cases, with a low rate of complications. However, 30% of patients require repeat dilation in 1 year despite optimal acid suppression therapy. This is in comparison to a 60% recurrence rate without adequate acid suppression therapy.
  • Poor prognostic factors include a lack of heartburn and significant weight loss at initial presentation.
  • The severity of initial stenosis and the type and size of dilator used have no effect on stricture recurrence.
• Surgical intervention
• • The outcome of surgery is highly dependent on the surgeon's experience and whether or not it is performed in high-volume centers.
  • Most surgical series report a good-to-excellent outcome in 77% of cases, with the range being 43-90%.
  • The repeat dilation rate is reported to be 1-43% after surgery, requiring 1-2 sessions at most.
  • Mortality and morbidity rates are reported to be less than 0.5% and 20%, respectively.
• Currently, no good controlled trials exist comparing the efficacy, outcome, and safety of surgery with aggressive medical management that includes PPIs and dilation as necessary.

Patient Education

• Reinforce the need for patients to comply with the usual antireflux precautions and lifestyle modifications.
• Encourage weight loss.
• Patients are told to eat smaller meals, avoid eating in a hurried fashion, and chew their food well.
• Ill-fitting dentures or poor dentition should be corrected if possible.
• Educate all patients about not taking medications known to cause esophagitis, including over-the-counter medications such as aspirin and nonsteroidal anti-inflammatory drugs.
• Inform all patients that the stricture recurrence rate is higher if they are noncompliant with PPI therapy.
• For excellent patient education resources, visit eMedicine's Heartburn/GERD/Reflux Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Reflux Disease (GERD) and Heartburn.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Being extremely thorough in determining the cause of the stricture in a timely fashion is important. This has a significant impact on the type of therapy advocated and the response and outcome of any individual therapeutic intervention.
• Patients should be well informed of the potential risks of esophageal dilation and its subsequent management and outcome. With adequate information, patients and their families will be better prepared to accept and deal with a bad outcome if it occurs.

Special Concerns

• Because most patients with strictures are elderly, ascertaining the surgical risk in each individual patient is important before embarking on any therapeutic intervention if a bad outcome occurs.
• Most peptic strictures (89%) are less than 25 mm in length and located in the distal esophagus; however, if one encounters a stricture in a different location or if the stricture is longer than 30 mm in length, consider other etiologies, including the following:
• • Zollinger-Ellison syndrome (obtain a serum gastrin)
  • Pill-induced esophagitis
  • Prolonged nasogastric intubation
  • Malignancy
• Use prophylactic antibiotics in high-risk cases as outlined by the American Heart Association and advocated by the ASGE.

MULTIMEDIA

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Media file 1:  Esophageal stricture. Endoscopic appearance of the distal esophagus showing a smooth stricture with a benign appearance.
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Media type:  Photo

REFERENCES

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• Agnew SR, Pandya SP, Reynolds RP. Predictors for frequent esophageal dilations of benign peptic strictures. Dig Dis Sci. May 1996;41(5):931-6. [Medline].
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• American Society for Gastrointestinal Endoscopy. Antibiotic prophylaxis for gastrointestinal endoscopy. Gastrointest Endosc. Dec 1995;42(6):630-5. [Medline].
• Attwood SE, DeMeester TR, Bremner CG. Alkaline gastroesophageal reflux: implications in the development of complications in Barrett''s columnar-lined lower esophagus. Surgery. Oct 1989;106(4):764-70. [Medline].
• Bell NJ, Burget D, Howden CW. Appropriate acid suppression for the management of gastro-oesophageal reflux disease. Digestion. 1992;51 Suppl 1:59-67. [Medline].
• Berenson GA, Wyllie R, Caulfield M. Intralesional steroids in the treatment of refractory esophageal strictures. J Pediatr Gastroenterol Nutr. Feb 1994;18(2):250-2. [Medline].
• Botoman VA, Surawicz CM. Bacteremia with gastrointestinal endoscopic procedures. Gastrointest Endosc. Oct 1986;32(5):342-6. [Medline].
• Cox JG, Winter RK, Maslin SC. Balloon or bougie for dilatation of benign oesophageal stricture? An interim report of a randomised controlled trial. Gut. Dec 1988;29(12):1741-7. [Medline].
• Dajani AS, Taubert KA, Wilson W. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. Jun 11 1997;277(22):1794-801. [Medline].
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Article Last Updated: Jun 27, 2006