BENIGN (PEPTIC) STRICTURE Group D Mamba - Medenilla

BENIGN (PEPTIC) STRICTURE Results from fibrosis that causes luminal constriction According to size Caused by Short strictures (usually 1-3cm long) spontaneous reflux Long, tubular peptic strictures persistent vomiting prolonged nasogastric intubation. Source: p.1851

BENIGN (PEPTIC) STRICTURE Clinical features Diagnosis General principles of Treatment

Clinical features Source: p.1851

GERD Regurgitation of sour material Heartburn Peptic Stricture Several years of heartburn preceding dysphagia Persistence of dysphagia Suggest development of Peptic Stricture

BENIGN (PEPTIC) STRICTURE Clinical 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) STRICTURE Clinical 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 Patient Benign Peptic Stricture 60 year old male (+) acid reflux Race 10-fold more common in whites than African Americans or Asians. Sex M>F (2 to 3x more common) Age Patients tend to be older, with a longer duration of reflux symptoms. Esophageal stricture, http://emedicine.medscape.com/

BENIGN (PEPTIC) STRICTURE Clinical features Patient Benign Peptic Stricture Had 10.5 pack years of smoking (+) acid reflux Frequency Strictures are estimated to occur in 7-23% of untreated patients with reflux disease. Gastroesophageal reflux disease accounts for approximately 70-80% of all cases of esophageal stricture. Esophageal stricture, http://emedicine.medscape.com/

BENIGN (PEPTIC) STRICTURE Clinical features Diagnosis General principles of Treatment

Diagnosis

BENIGN (PEPTIC) STRICTURE Diagnosis

BENIGN (PEPTIC) STRICTURE Clinical features Diagnosis General principles of Treatment

General principles of Treatment For patients [with GERD] + associated peptic stricture 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 General principles of Treatment Source: p.1852

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.

Composite score allowing stricture grading Diameter of the stricture (mm) Score >11 1 6-10 2 ≤5 3 B Length of the stricture (mm) <30 30-50 >50 C Response to dilation Good 1 Poor 2 Composite score allowing stricture grading Type I 4-5 Type II 6-7 Type III 8-9 Source: Modified from Braghetto et al

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’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 : 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

Surgical Therapy 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.

BENIGN (PEPTIC) STRICTURE Non-pharmacologic treatment Diet Avoid 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.