Oesophageal stricture (OS)
What are the causes of oesophageal stricture?
The majority of oesophageal strictures are reflux related. Other causes are malignancy, anastomotic, sclerotherapy, radiation, medication, and corrosive induced strictures, and rings and webs.
Eosinophilic oesophagitis is a recently described emerging cause of oesophageal stricture.
Discuss the role of barium swallow as the first investigation in the diagnosis of dysphagia?
Patients with proximal dysphagia may have a pharyngeal pouch, post cricoid web etc which increases the risk of perforation on endoscopy. Barium swallow may be considered as an initial investigation for investigation of proximal dysphagia, however an endoscopy is safe as an initial test in experienced hands.
Discuss the contraindications to oesophageal dilatation?
- Active perforation
- Severe cardio respiratory disease is a relative contraindication
- The risk is increased in patients with a pharyngeal or cervical deformity or a large thoracic aneurysm.
- Concurrent radiotherapy is not a contraindication for dilatation
Discuss the preparation for dilatation?
- Stop warfarin or convert to low molecular weight heparin (if high risk)
- Aspirin or NSAIDs can be continued
- Antibiotic prophylaxis is not needed
Discuss the types of oesophageal dilators?
Two types of oesophageal dilator are available:
- Mechanical (push dilator or bougie like Maloney dilator or Savary-Gilliard dilators)
- Balloon dilator
Mechanical dilators exert a longitudinal and radial force whereas balloon dilators deliver radial force only. Balloon dilators are widely used and may be passed through the scope. Both mechanical and balloon dilatators are safe and efficacious. The principal disadvantage of balloon dilators is their cost.
What is the diameter to which the obstruction should be dilated?
Dysphagia occurs when the oesophageal diameter is less than 13 mm. Thus a diameter of 13-15mm is generally accepted as the end point of dilatation. A few patients will require greater diameters for symptom relief. Large calibre dilators (16–20 mm) are also advised in the treatment of patients with Schatzki’s rings
Discuss the size of the balloon to be used for first dilatation?
Stricture diameter can be estimated by comparing the stricture to the outer diameter of the endoscope (outer diameter is around 9 mm for diagnostic scopes and 11 mm for therapeutic scopes). A 12 mm balloon can be used for stricture diameter of 5mm or more. A 10 mm balloon should be used for tighter strictures.
How quickly dilatation should be achieved?
No more than three consecutive dilatations should be performed in one session (‘rule of three’). 3X1mm increments- i.e. the luminal diameter should be increased by no more than 2 mm.
Weekly dilatation until 15mm dilatation is a common strategy. As a general rule, the last balloon size in the previous session can be used first.
In some patients symptoms tend to recur rapidly following dilation to adequate diameter of 14-15 mm. Such patients require more frequent dilations based upon symptoms.
Discuss the role of radiological screening?
This is not essential when the anatomy is well defined and the wire passes easily (with wire guided mechanical dilators) into the stomach. Through the scope balloon dilatation is performed under direct endoscopic visualisation. Fluoroscopy is not needed if the passage of the balloon into the stomach is clearly visible or if the patient has undergone prior endoscopy (assuring that there is no unexpected pathology or an anatomical variant distal to the stricture)
Radiographic screening is useful when the stricture is tortuous or complex or associated with a large hiatus hernia or diverticulae. It may also be of value when the
guidewire or the balloon meets with resistance during passage through the
stricture.
Discuss the role of CXR or contrast swallow post dilatation?
These investigations are not essential but should be performed urgently in patients who develop pain, breathlessness, fever, or tachycardia.
A chest x ray may show pneumomediastinum, pneumothorax, air under the diaphragm, or a pleural effusion but normal appearances do not exclude
perforation and, if there is any clinical suspicion, a water soluble contrast study should be performed.
Discuss the complications of oesophageal dilatation?
- Perforation (benign- 1.1%, malignant- 6.4%)
- Pulmonary aspiration
- Bleeding
Discuss the safety of mucosal biopsy before dilatation?
Biopsies, if needed, are taken after dilatation, although there is no evidence that pre dilatation biopsy is harmful
Discuss the management of benign refractory strictures?
Options to prevent stricture recurrence:
- Consider 24 hour pH monitoring on PPI therapy to check on adequacy of acid suppression. Consider increased PPI or anti-reflux surgery as needed.
- Intralesional injection of steroid may reduce stricture recurrence following dilatation. Prior to dilatation, 0.5 ml of triamcinolone acetonide (40mg/ml diluted 1:1 with saline) is injected in four quadrant in the stricture.
- Temporary placement of non metal expandable stents can be effective. Further studies are needed
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