General Principles Of Treatment

Treatment Goals To relieve the symptoms of Benign (Peptic Stricture) To improve patient’s nutritional status.

Pharmacological Endoscopic surgical

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.

CResponse to dilation Good1 Poor2 Composite score allowing stricture grading Type I4-5 Type II6-7 Type III8-9 Source: Modified from Braghetto et al A Diameter of the stricture (mm) Score > ≤53 BLength of the stricture (mm) < >503

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 dilatationPPI PPI therapy has to be individualized, depending on the level of reduction in acid exposure as assessed by 24-hour pH monitoring.PPI

PPI’s Omeprazole (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’s Pantoprazole (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 : 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.

Non-Pharmacologic Diet Patients are told to avoid fatty and spicy foods, alcohol, tobacco, chocolate, and peppermint. Patients should eat smaller meals, avoid eating in a hurried fashion, and chew their food well. Patients should be encouraged not to eat at least 2-3 hours before bedtime. Weight reduction should be encouraged. Ill-fitting dentures or poor dentition should be corrected if possible.