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

BENIGN (PEPTIC) STRICTUREDiagnosis

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 TREATMENTTo relieve dysphagia Endoscopic dilationTo relieve reflux Vigorous treatment of GERD

Anti-secretory agents Anti-reflux surgery Lifestyle modification

*To improve nutritional status *Diet control

Pretreatment Classification

• Consider severity of the condition and complications following treatment

• preoperative evaluation, preoperative and pretreatment assessment of the patient, as well as the character of the stricture.

C Response to dilation

Good 1

Poor 2

Composite score allowing stricture gradingType I 4-5

Type II 6-7

Type III 8-9

Source: Modified from Braghetto et al

A Diameter of the stricture (mm) Score

>11 1

6-10 2

≤5 3

B Length of the stricture (mm)

<30 1

30-50 2

>50 3

Medical Care

• more emphasis has been placed on mechanical dilatation

• coexistent esophagitis has been relatively ignored

• several studies have demonstrated that aggressive acid suppression using PPIs is extremely beneficial in the initial treatment, as well as long-term management.

Medical Care

• Studies have shown that aggressive acid-suppression therapy with PPIs both improve esophagitis and 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

• Three types:– mercury field bougies – polyvinyl bougies – balloon dilators– Usually the physician passes a series of dilators or

gradually increases the diameter of the balloon to stretch out the stricture.

– complications such as perforation and bleeding occurred in approximately 0.5% of all esophageal dilation procedures

Surgical Therapy• Conservative antireflux surgery with classic

fundoplication has been employed for peptic stricture patients with a 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

• More mutilating surgical procedures, incorporating partial gastrectomy, vagotomy with or without biliary diversion, or duodenal switch procedures have been introduced.

• Esophageal resection has been proposed in patients with severe stricture, poor contractility, or high-grade dysplasia.

Surgical Therapy

BENIGN (PEPTIC) STRICTURENon-pharmacologic treatment

DietAvoid fatty and spicy foods, alcohol, tobacco,

chocolate, and peppermint. Not to eat at least 2-3 hours before bedtime.

Should eat smaller meals, avoid eating in a hurried fashion, and chew their food well.

Weight reduction Ill-fitting dentures or poor dentition should be

corrected if possible.