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Benign esophageal stricture — Clinical Guidelines

Overview

Benign esophageal strictures are narrowing of the esophagus not caused by malignancy, often resulting from chronic inflammation, peptic injury, or corrosive injury, leading to dysphagia and nutritional compromise. 1 11

Diagnosis

Clinical Presentation: Dysphagia, weight loss, and regurgitation.

Endoscopy: Visualizes stricture location and severity.

Biopsy: Rules out malignancy; essential in elderly patients.

Manometry: Evaluates esophageal motility and lower esophageal sphincter function.

Imaging: Barium swallow to assess stricture length and location. 11

Management

First-Line Treatments:

- Esophageal Dilation: Regular dilation sessions to widen the stricture. 10 1 9 - Medical Therapy: Proton pump inhibitors (PPIs) for peptic strictures to reduce acid exposure. 12 6

Adjunctive Treatments:

- Self-Expanding Metallic Stents: Used in refractory cases, particularly in pediatric and complex adult patients. 2 3 7 8 - Intralesional Steroid Injections: Emerging therapy for reducing inflammation and stricture recurrence. 4 - Surgical Interventions: Fundoplication or other reconstructive surgeries for severe, refractory cases. 5 6

Special Populations

Pediatrics: Self-expanding stents can be safely and effectively used in children with corrosive strictures. 2

Elderly: Fiber-optic endoscopic dilation combined with acid suppression therapy (e.g., cimetidine) is effective and safe. 12

Comorbidities: Careful evaluation for malignancy is crucial, especially in elderly patients. 11

Key Recommendations

Regular Esophageal Dilation is effective for managing benign esophageal strictures and should be performed under appropriate anesthesia based on patient condition and stricture severity. (Evidence: Moderate 1 10)

Proton Pump Inhibitors (PPIs) should be considered as first-line medical therapy to reduce acid exposure and promote healing in peptic strictures. (Evidence: Moderate 6 12)

Self-Expanding Metallic Stents can be utilized as an adjunctive treatment in refractory cases, particularly in pediatric patients and those with complex strictures, though outcomes vary. (Evidence: Weak 2 3 7 8)

Surgical Options including fundoplication are recommended for severe, refractory strictures where medical and endoscopic treatments fail. (Evidence: Moderate 5 6)

Careful Evaluation for Malignancy is essential, especially in elderly patients presenting with esophageal strictures. (Evidence: Expert opinion 11)

References

1 Lerner MZ, Bourdillon AT, Dai F, Brackett A, Kohli N. Safety considerations for esophageal dilation by anesthetic type: A systematic review. American journal of otolaryngology 2021. link 2 Zhang C, Yu JM, Fan GP, Shi CR, Yu SY, Wang HP et al.. The use of a retrievable self-expanding stent in treating childhood benign esophageal strictures. Journal of pediatric surgery 2005. link 3 Pintus C, Valeri S, Riccioni M, Ciletti S, Coppola R, Perrelli L. Recurrent peptic stenosis of the esophagus: treatment with a self-expanding metallic stent. Surgical laparoscopy, endoscopy & percutaneous techniques 2000. link 4 Streeter BL. Intralesional steroid injection therapy. Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates 1999. link 5 Mamazza J, Schlachta CM, Poulin EC. Surgery for peptic strictures. Gastrointestinal endoscopy clinics of North America 1998. link 6 Ferguson MK. Medical and surgical management of peptic esophageal strictures. Chest surgery clinics of North America 1994. link 7 Grundy A. The Strecker Esophageal stent in the management of oesophageal strictures: technique of insertion and early clinical experience. Clinical radiology 1994. link81831-8) 8 Song HY, Do YS, Han YM, Sung KB, Choi EK, Sohn KH et al.. Covered, expandable esophageal metallic stent tubes: experiences in 119 patients. Radiology 1994. link 9 Maxton DG. Guide wire distance marks for oesophageal dilatation. Gut 1990. link 10 Tucker LE. Esophageal dilation. Six-year experience in a small community hospital. Missouri medicine 1989. link 11 Henderson RD. Management of the patient with benign esophageal stricture. The Surgical clinics of North America 1983. link43090-2) 12 Croker JR, Vallon AG, Cotton PB. Benign oesophageal stricture in the elderly--use of cimetidine and fibre-optic dilatation. Age and ageing 1980. link 13 McDonald HF. Right pneumothorax following fiberoptic oesophageal dilatation. Endoscopy 1978. link 14 Holden MP, Wooler GH. Mousseau-Barbin tubes for benign strictures of the oesophagus. Thorax 1971. link

Benign esophageal stricture