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

2. 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

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

4. Clinical features
Source:
p.1851

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

6. 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,

7. BENIGN (PEPTIC) STRICTURE Clinical features
Patient
Benign Peptic Stricture
Physical exam
BMI: 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,

8. 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,

9. 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,

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

11. Diagnosis

12. BENIGN (PEPTIC) STRICTURE Diagnosis

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

14. 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

15. 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.

16. 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

17. 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.

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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.