1. BENIGN (PEPTIC) STRICTURE Group D Mamba - Medenilla

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

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

4. Clinical features Source: p.1851

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

6. BENIGN (PEPTIC) STRICTURE Clinical features PatientBenign 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/

7. BENIGN (PEPTIC) STRICTURE Clinical features PatientBenign 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/

8. Patient 60 year old male (+) acid reflux Benign Peptic Stricture 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

9. 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. PatientBenign Peptic Stricture Esophageal stricture, http://emedicine.medscape.com/

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

11. Diagnosis Source: p.1851 1.History 2.Therapeutic Trial with a PPI (eg omeprazole, 40 mg BID for 1 wk)

12. Barium swallow Barium swallow showing peptic stricture due to Gastro-esophageal reflux

13. 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

14. 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

15. 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

16. Histologic Findings Initial histologic changes in the peptic stricture process – Edema, cellular infiltration, basal cell hyperplasia, and vascular changes with a slight increase in type III collagen deposition on healing If untreated, the process can lead to progressive inflammation and ulceration involving the submucosa and muscularis mucosa – Muscular layer and intrinsic nervous system damage of the esophagus  Type I Collagen deposition  Scar tissue and stricture formation

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

18. For patients [with GERD] + associated peptic stricture Source: p.1852 GOALTREATMENT To relieve dysphagiaEndoscopic dilation To relieve refluxVigorous treatment of GERD  Anti-secretory agents  Anti-reflux surgery  Lifestyle modification *To improve nutritional status*Diet control

19. 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.

20. 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 >111 6-102 ≤53 BLength of the stricture (mm) <301 30-502 >503

21. Medical Care Several studies have demonstrated that aggressive acid suppression using PPIs is extremely beneficial in:  initial treatment  long-term management

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Specific Treatment Plan for the Patient THERAPYREQUEST FOR/PRESCRIBE EndoscopicEndoscopic Balloon Dilation SurgicalFundoplication PharmacologicDouble Dose PPI - (Omeprazole 40mg PO qam 30 minutes ac) Non-PharmacologicLifestyle change (esp. cessation of smoking) Diet Modification

30. Thank you!