BENIGN (PEPTIC)

STRICTURE

Group DMamba - Medenilla

BENIGN (PEPTIC) STRICTURE

• Peptic Stricture– Results from fibrosis that causes luminal

constriction

Source:p.1851

According to size Caused byShort strictures(usually 1-3cm long)

spontaneous reflux

Long, tubular peptic strictures

• persistent vomiting • prolonged nasogastric intubation.

BENIGN (PEPTIC) STRICTURE

Clinical features

Diagnosis

General principles of Treatment

Clinical features

Source:p.1851

BENIGN (PEPTIC) STRICTUREClinical features

Patient Benign Peptic Stricture• History

– Difficulty of swallowing– Regurgitation of sour material– Chest pain after eating– Copious sputum upon waking up– Dysphagia to solid foods– Occasional vomiting of previously

taken in food– Symptoms relieved by Omeprazole

but would recur intermittently– Weight loss of 8 kg

• History– Progressive dysphagia

to solid food– Heartburn and chest

pain– Odynophagia– Food impaction– Weight loss

Esophageal stricture, http://emedicine.medscape.com/

BENIGN (PEPTIC) STRICTUREClinical features

Patient Benign Peptic Stricture

• Physical exam– BMI: 17.63 kg/m^2– Vital signs normal– Pulmonary: No crackles nor

wheezes– Cardiac: Heart sounds

unremarkable– Abdominal: scaphoid

abdomen, non tender, no masses

– Neurologic: no evident deficit

• Physical exam– Physical examination

frequently does not provide clues to the cause of dysphagia.

– Assess nutritional status

Esophageal stricture, http://emedicine.medscape.com/

BENIGN (PEPTIC) STRICTURE

Clinical features

Diagnosis

General principles of Treatment

Diagnosis

Source:p.1851

1. History2. Therapeutic Trial

with a PPI (eg omeprazole, 40 mg BID for 1 wk)

Barium swallow

Barium swallow showing peptic stricture due toGastro-esophageal reflux

Upper Endoscopy / EGD

• 8-hour fasting, Flexible scope is advanced under direct vision into upper GIT

• Alarm Symptoms that indicate the need for EGD– Weight loss, Recurrent vomiting, Dysphagia,

Bleeding, Anemia

• Most serious complications of EGD: perforation, aspiration, respiratory depression from excessive sedation

Barium Esophagram

• Provides objective baseline information: – location, length– stricture diameter– esophageal wall consistency– irregularity

• Complementary to endoscopic findings• May be more sensitive than endoscopy for detection

of subtle narrowings of the esophagus• 100% sensitivity with luminal diameter <9 mm• 90% sensitivity with luminal diameter >10 mm

24-Hour pH Monitoring

• Identifies the presence and extent of reflux• Helpful in evaluating and documenting the

adequacy of therapy in patients who remain symptomatic despite treatment with PPIs or fundoplication

BENIGN (PEPTIC) STRICTURE

Clinical features

Diagnosis

General principles of Treatment

General principles of Treatment

• For patients [with GERD] + associated peptic stricture

Source:p.1852

GOAL TREATMENT

To relieve dysphagia Endoscopic dilation

To relieve reflux Vigorous treatment of GERD Anti-secretory agents Anti-reflux surgery Lifestyle modification

*To improve nutritional status *Diet control

Medical Care

• Several studies have demonstrated that aggressive acid suppression using PPIs is extremely beneficial in:

initial treatment long-term management

PPI’s for aggressive acid-suppression

• Improve esophagitis• Decrease the need for subsequent esophageal

dilatation

• PPI therapy has to be individualized– depending on the level of reduction in acid

exposure as assessed by 24-hour pH monitoring.

PPI’sOmeprazole (Prilosec)

Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump.

Adult : 20 mg PO qam 30 min ac; may increase bid

Lansoprazole (Prevacid)Suppresses gastric acid secretion by specifically inhibiting H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.

Adult : 30 mg PO qam 30 min ac; may increase to 30 mg bid

Rabeprazole (Aciphex)Decreases gastric acid secretion by inhibiting the parietal cell

H+/K+ ATP pump.Adult :20 mg PO qam 30 min ac; may increase to 20 mg

PO bid if necessary

PPI’sPantoprazole (Protonix)

Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump.

Adult : 40 mg PO qam 30 min ac; may increase to bid

Esomeprazole magnesium (Nexium)S-isomer of omeprazole. Inhibits gastric acid

secretion by inhibiting H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cells.

Adult : 20-40 mg PO qd for 4-8 wk

Surgical Care (endoscopic and surgical modalities )

• choice of dilator and technique is dependent on many factors, the most important being stricture characteristics

• factors, including patient tolerance, operator preference, and experience.

• Dilatation therapy should be tailored individually

Endoscopic Therapy

– Usually the physician passes a series of dilators or gradually increases the diameter of the balloon to stretch out the stricture.

– Complications : ~0.5% of all esophageal dilation procedures

• Perforation• Bleeding

Surgical Therapy

• Classic fundoplication– long-term success rate ranging from 65 to 90%.

• Laparoscopic approach report a 12% failure rate, whereas others demonstrate significantly higher recurrence rates (25%).

• Esophageal lengthening gastroplasty of the Collies-Nissen type or Collies-Belsey Mark IV type have been proposed

Specific Treatment Plan for the PatientTHERAPY REQUEST FOR/PRESCRIBEEndoscopic Endoscopic Balloon DilationSurgical FundoplicationPharmacologic Double Dose PPI -

(Omeprazole 40mg PO qam 30 minutes ac)

Non-Pharmacologic Lifestyle change(esp. cessation of smoking)Diet Modification

Thank you!