BENIGN (PEPTIC) STRICTURE

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

2. BENIGN (PEPTIC) STRICTURE • Peptic Stricture • Results from fibrosis that causes luminal constriction Source: p.1851

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

4. Clinical features Source: p.1851

5. 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/

6. 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/

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

8. History Therapeutic Trial with a PPI (egomeprazole, 40 mg BID for 1 wk) Diagnosis Source: p.1851

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

10. 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 • Diameter: > 10 mm • 100% sensitivity with luminal diameter <9 mm • 90% sensitivity with luminal diameter >10 mm

11. 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

12. 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

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

14. For patients [with GERD] + associated peptic stricture 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.

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 : 20-40 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) STRICTURENon-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.