eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Stricture: Follow-up

Author: Rajeev Vasudeva, MD, FACG, Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine
Contributor Information and Disclosures

Updated: Jun 27, 2006

Follow-up

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.

Inpatient & Outpatient Medications

  • 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

Medicolegal 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.
 


More on Esophageal Stricture

Overview: Esophageal Stricture
Differential Diagnoses & Workup: Esophageal Stricture
Treatment & Medication: Esophageal Stricture
Follow-up: Esophageal Stricture
Multimedia: Esophageal Stricture
References
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Further Reading

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Keywords

esophageal stenosis, peptic stenosis, reflux stricture, peptic stricture, postoperative strictures, corrosive strictures, gastroesophageal reflux–induced esophagitis, gastroesophageal reflux disease, dysphagia

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Contributor Information and Disclosures

Author

Rajeev Vasudeva, MD, FACG, Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine
Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Maurice A Cerulli, MD, FACG, Chief, Division of Gastroenterology and Hepatology, Associate Professor of Clinical Medicine, Department of Internal Medicine, Division of Gastroenterology, New York Methodist Hospital, Cornell University
Maurice A Cerulli, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Medical Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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