CHAPTER100 EsophagealDilation:AnOverview

1 JWST654-c100 JWST654-TalleyPrinter: Yet to ComeJuly 4, 2016 14:6 279mm 216mmCHAPTER 100 Esophageal Dilation: An OverviewParth J. parekh and David A. JohnsonDepartment of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USAS ummaryEsophageal strictures may develop from both benign and malig-nant causes. Patients with esophageal strictures typically presentwith progressive dysphagia for solids, which if left untreatedmay progress to include liquids. Esophageal dilation is frequentlyrequired for the symptomatic management of dysphagia.

2 There area number of available options for successful dilation of most stric-tures, as well as adjunctive techniques reserved for more refractory cases. In order to optimize therapy and minimize risk, it is essentialto fully understand the underlying cause and anatomy of the for luminal restoration are important as, in each case, thesefactors may need to be altered to suit the etiology and pathology ofthe 58-year-old female presents with a 3-month history of intermittentbut not progressive solid food dysphagia.

3 Food seems to be catchingin the mid-sternal area. She has not noted this with liquids or softfoods, but has symptoms in particular with meats, fresh vegetables,doughy bread products, and pasta. She has no associated medications include alendronate, a multivitamin, and rare-useaspirin, but no other non-steroidal anti-inflammatory drugs(NSAIDs).Physical exam is normal. The physician alertly notes that thepatient is taking bisphosphonate and is concerned about apill-induced stricture. Barium X-ray is considered, but as this seems tobe a non-complex stricture, the patient is instead referred forendoscopy.

4 The goals of therapy are discussed: the target is tore-establish normal dietary shows a luminal narrowing estimated (using the openbiopsy forceps) to be 14 mm. The stricture is immediately above theesophagogastric junction and there is no evidence of esophagitis. Ahydrostatic balloon is chosen and dilation is performed using thegraduated 15 18 mm dilator. Care is taken to deflate the stomachbefore the dilation and to deflate the balloon between sizeincrements in order to assess for mucosal disruption.

5 With the 18mmballoon, there is a slight mucosal tear in the area of patient is counseled to avoid her bisphosphonate for a monthand to discuss alternative therapy with her primary physician. She isgiven a proton pump inhibitor (PPI) for 8 weeks and advised to followa soft diet (cutting food into small pieces) for several weeks, beforeslowly advancing to a more normal diet as tolerated. She is instructedto notify the gastroenterologist if persistent or recurrent dysphagia isevident or if she develops strictures arise from an intrinsic disease (such as inflam-mation, fibrosis, or neoplasia) that narrows the esophageal lumen,an extrinsic disease compromising the esophageal lumen by director indirect invasion, or diseases disrupting esophageal peristalsisand/or lower esophageal sphincter (LES) function.

6 Esophageal stric-tures are further subdivided into those with a benign and thosewith malignant origin. The etiologies of benign strictures includegastroesophageal reflux esophagitis, Schatzki s ring, radiation, caus-tic ingestion, nasogastric intubation with acid reflux, primary orsecondary pill-induced injury, anastomotic stricture with relatedischemia or history of an anastomotic leak, ringed strictures asso-ciated with eosinophilic esophagitis, and several rare strictures may develop as a result of local tumor growthor metastatic disease [1].

7 For centuries, the cornerstone of therapy has been ,whencarvedwhale-bone was used to treat achalasia. Bougienage was first reportedin the early 1800s, and since then the equipment used to treatesophageal strictures has evolved considerably to include flexi-ble bougies, wire-guided dilators, and through-the scope ballooncatheters [2].The goal of therapy is ultimately to provide adequate symp-tomatic relief and prevent the recurrence of stricture formation. Thepatient s dietary habits and nutritional needs must be consideredwhen constructing an appropriate treatment plan.

8 Additionally, itis important to differentiate the structural characteristics betweensimple and complex esophageal strictures. This chapter will pro-vide an update on the categories of esophageal stricture, categoriesof esophageal dilator, and techniques used for esophageal of Esophageal StrictureEsophageal strictures are categorized by structural anatomy as beingsimple or complex depending on size, symmetry, and the passageof a diagnostic upper endoscope [3]. Simple strictures are concen-tric (with a luminal diameter of 12 mm) or symmetric (easilyCHAPTER 100 Practical Gastroenterology and Hepatology Board Review Toolkit, , , , Keith D.)

9 Lindor. 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. Companion website: : Yet to ComeJuly 4, 2016 14:6 279mm 216mm2 Esophageal Dilation: An OverviewTable of simple versus complex for passage ofendoscopeYesNo (typically)LengthShort (<2 cm)Long (>2cm)FocalYesNoAngulation/irregularityNoY es (typically)EtiologyPepticShatzki s ringAnastomoticPill-inducedCaustic ingestionMalignancyPhotodynamic therapyRadiationPreferred dilation methodBalloon or rigid dilator Rigid dilatorFluoroscopyRarely neededRecommendedDilations1 3 (typically) 3 Risk of recurrenceLowHighallow passage of a diagnostic upper endoscope).

10 Conversely, com-plex strictures are defined as having a luminal diameter of 12 mm,as being asymmetric with angulation, or as not having the ability topass a diagnostic upper endoscope. Table summarizes the dif-ferences in characteristics between a simple and a complex esophageal strictures tend to be short, focal, and straight,or to have a diameter that is sufficient to allow the passageof a normal-diameter endoscope. Common etiologies of sim-ple esophageal strictures include gastroesophageal reflux disease(GERD) (up to 70% of cases), Schatzki s ring, and membranouswebs.