benign (peptic) stricture
DESCRIPTION
BENIGN (PEPTIC) STRICTURE. Group D Mamba - Medenilla. BENIGN (PEPTIC) STRICTURE. Peptic Stricture Results from fibrosis that causes luminal constriction. Source: p.1851. BENIGN (PEPTIC) STRICTURE. Clinical features. Diagnosis. General principles of Treatment. Clinical features. - PowerPoint PPT PresentationTRANSCRIPT
BENIGN (PEPTIC)
STRICTURE
Group DMamba - Medenilla
BENIGN (PEPTIC) STRICTURE
• Peptic Stricture– Results from fibrosis that causes luminal
constriction
Source:p.1851
According to size Caused byShort strictures(usually 1-3cm long)
spontaneous reflux
Long, tubular peptic strictures
• persistent vomiting • prolonged nasogastric intubation.
BENIGN (PEPTIC) STRICTURE
Clinical features
Diagnosis
General principles of Treatment
Clinical features
Source:p.1851
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/
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/
BENIGN (PEPTIC) STRICTURE
Clinical features
Diagnosis
General principles of Treatment
Diagnosis
Source:p.1851
1. History2. Therapeutic Trial
with a PPI (eg omeprazole, 40 mg BID for 1 wk)
Barium swallow
Barium swallow showing peptic stricture due toGastro-esophageal reflux
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
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
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
BENIGN (PEPTIC) STRICTURE
Clinical features
Diagnosis
General principles of Treatment
General principles of Treatment
• For patients [with GERD] + associated peptic stricture
Source:p.1852
GOAL TREATMENTTo relieve dysphagia Endoscopic dilationTo relieve reflux Vigorous treatment of GERD
Anti-secretory agents Anti-reflux surgery Lifestyle modification
*To improve nutritional status *Diet control
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.
C Response to dilation
Good 1
Poor 2
Composite score allowing stricture gradingType I 4-5
Type II 6-7
Type III 8-9
Source: Modified from Braghetto et al
A Diameter of the stricture (mm) Score
>11 1
6-10 2
≤5 3
B Length of the stricture (mm)
<30 1
30-50 2
>50 3
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’sOmeprazole (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’sPantoprazole (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
• 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
BENIGN (PEPTIC) STRICTURENon-pharmacologic treatment
DietAvoid 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.