Git j club dysphagia endoscopy.

Guideline:
The role of endoscopy in the evaluation&
management of dysphagia.
GIE; 79, No 2 : 2014
Prepared by:
Dr.Mohamed Al-Shekhani.

Causes of esophageal dysphagia:
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Dysphagia result from structural or motor disorders.
Structural disorders typically have dysphagia with solids alone.
Motility disorders present with both liquid & solid food dysphagia.
Structural disorders include inflammatory&malignant conditions.
Benign inflammatory strictures result from collagen&fibrous tissue
deposition in patients with severe or chronic inflammation.
Malignan strictures result from intrinsic luminal tumor growth or
extrinsic compression.
Peptic strictures, GERD-related, 80% of all benign
strictures, decreasing because of the widespread use of PPI.
EoE is recognized as a common benign cause.
Motility disorders: achalasia,diffuse esophageal
spasm, hypomotility of scleroderma& other CT disorders.

The role of endoscopy:
• EGD is an effective tool for diagnosis& management of dysphagia.
• Esophageal dilation is a therapeutic procedure performed for the
management of dysphagia.
• Endoscopy is indicated to:
• Determine the underlying etiology.
• Exclude malignant&premalignant conditions.
• Assess the need for therapy.
• Perform therapy, such as dilation.
• The primary indication for dilation is to:
• Provide immediate & durable symptomatic relief of dysphagia.
• In contrast to mechanical stenoses, motility disorders may not
respond to dilation, with exception of achalasia.

The role of endoscopy:
• Biopsy specimens should be obtained when a malignancy is
suspected clinically or endoscopicaly.
• Biopsies should be obtained from the proximal &distal esophagus
to evaluate for EoE in patients with:
• Dysphagia & endoscopic findings suggestive of the disorder or
• Dysphagia without typical endoscopic findings of EoE but
without obvious esophageal mechanical obstruction.
• Mucosal biopsies performed in conjunction with dilation do not
appear to confer any additional risk for perforation.
• Retroflexion of the endoscope before dilation, when possible, to
evaluate for malignancy or varices in the gastric cardia, is another
important part of the examination & is one of the quality
indicators for EGD.

Esophageal strictures: types
• 1. Simple stricture: short < 2cms with concentric lumen with a
diameter of = > 12 mm & traversed easily with an endoscope.
• A complex stricture: usually longer >2 cm, angulated or
irregular, diameter of > 12 mm with a higher rate of recurrence & an
increased risk for dilation-related adverse events &may be
associated with a large hiatal hernia, esophageal diverticula, or TEF.
• The severity of a stricture can be estimated by the resistance
encountered with passage of the diagnostic 9 mm endoscope.
• A mild stricture allows passage without resistance, a moderate
stricture offers increased resistance, whereas a severe stricture may
not be traversable.
• The diameter of a stricture can be objectively measured on barium
or by determining the maximal sized barium tablet that can pass
through the lumen.

Esophageal strictures: types
• Dysphagia caused by extrinsic compression responds poorly to
esophageal dilation while most malignant strictures respond to
dilation, but symptomatic relief may be only short term additional
treatment with stent placement may be necessary.
• In malignant strictures, dilation facilitates feeding gastrostomy tube
placement, palliative stenting,completion of the endoscopic
examination, including staging with EUS.

Type of eso dilators:
• Weighted push type (Maloney; Medovations, Milwaukee, Wis;
Teleflex Medical, Research Triangle Park, NC).
• Polyvinyl wire – guided dilators (Savary-Gilliard; Cook
Medical, Winston-Salem, NC&American ConMed, Utica, NY)
• Balloon dilators (wire-guided & through-the-scope [TTS]).
• Bougie dilators rely on tactile perception to determine the
amount of resistance encountered with passage through eso.
• Maloney dilators:16F - 60F, passed into the esophagus blindly or
under fluoroscopic guidance,can be used without sedation, may be
used for self-dilation by select patients.
• These dilators should not be used for narrow,complex strictures
because of the possibility that they could buckle above the
stricture & result in perforation.

• Polyvinyl dilators (Savary-Gilliard/ American) have a more
tapered rigid tip than Maloney dilators& a central hollow core for
passage of a guidewire,16F-60F, marked with a radiopaque band.
• American dilators have a shorter tapered tip impregnated with
barium throughout.
• PE balloon dilators include single-diameter&multiple-size balloon
dilators used over a guidewire [OTW]) or (TTS).
• The multiple-size balloons are designed to expand to 3 diameters
useful for sequential dilations with a single passage of the dilator.
• Smaller balloons (up to 20 mm) for dilation of strictures, whereas
larger (30 - 40 mm) for pneumatic dilation in achalasia.
• TTS dilators are used more commonly than OTW dilators for
safety& advantage of dilation under direct visualization.
• Smaller caliber wires may be advantageous in cannulation of
severe strictures.

• Bougie dilators exert both radial&axial forces along the entire
length of the stricture.
• Balloon dilators exert only radial force along the length of the
stricture(called hoop stress) a product of the diameter& pressure
within the balloon.
• The opposing static force of the stricture creates an hourglass
waist in the balloon.
• The dilating force of a balloon dilator is inversely proportional to
the diameter of the waist.
• A larger balloon that exerts a higher radial force requires less
pressure for dilation but may be associated with a higher risk for
perforation.
• The dilating force is also dependent on the surface area of the
stricture, with more effective dilation of longer strictures.

Patient preparation:
• Usually performed in the OP.
• No intake of solids for 6 hours& clear liquids 2 hs before procedure.
• If eso stasis because of achalasia, diverticula, or tight strictures, may
require a prolonged fast or NGT to minimize aspiration.
• Moderate sedation for dilation in the majority of patients& deep
sedation or general anesthesia may be required for complex
procedures or significant comorbidities.

• Esophageal dilation is high-risk procedure for bleeding.
• In low-risk for thromboembolic events, oral anticoagulation with
warfarin should be held for 5 - 7 days before the procedure.
• Bridging therapy is often recommended for patients who are at high
risk for thromboembolic events.
• Thienopyridines (eg, clopidogrel) usually are held for 7 - 10 days
before the procedure.
• Aspirin may be continued before esophageal dilation, depending on
indication for antiplatelets &individual patient characteristics.
• In DAT, dilation should be deferred, if possible, until the patient has
received the minimum length of therapy recommended by the ACG/
AHA guidelines.
• The overall risk of infective endocarditis is extremely low , so
prophylactic antibiotics not recommend.

• All necessary equipments hould be available before the procedure.
• Standard, pediatric, ultrathin endoscopes, fluoroscopy should be
available when dilation of a complex stricture is anticipated.
• Additional accessories: biopsy forceps, needleknife papillotome,
steroids (triamcinolone) for injection.
• The endoscopist should be supported by assistants who are
experienced in monitoring patient comfort & safety throughout the
examination &familiar with the endoscopic tools.
• Patients should be closely monitored during& after esophageal
dilation to detect adverse events.

Peptic strictures:
• Maloney push-type dilators &balloon dilators has similar efficacy.
• Should be treated with acid suppression to prevent recurrence.
• Dilation under fluoroscopic guidance, guidewire assistance, or
direct visualization is recommended for complex peptic strictures.
• The degree of dilation in a session should be based on the severity
of the stricture “rule of 3”
• The initial dilator is selected based on the stricture diameter; the
same size or not >1 - 2 mm larger than the lumen of the stricture.
• After moderate resistance is encountered, typically no >3
consecutive dilators in increments of 1 mm are passed in a single
session.
• The “rule of 3” does not apply to balloon dilation& inflation of a
single, appropriately sized balloon dilator should be done.
• Incremental dilations of > 3 mm may be safe for simple strictures.

Peptic strictures:
• 40% recurrent dysphagia despite acid suppressive therapy,
requiring repeat dilations.
• The most common causes for recurrence:
• Complex strictures.
• Untreated acid reflux.
• Undiagnosed EoE.

Schatzki ring:
• Dilation with a single, large (16 -20 mm) dilator leads to rupture
of the Schatzki ring&symptomatic relief in almost all patients.
• Adjunctive methods: electrocautery incision with needle-knife
papillotome& 4-quadrant biopsies of the ring BZ of association
between EoE& Schatzki ring& biopsies of the esophagus should
be considered if there is a clinical suspicion of EoE.
• If a Schatzki ring cannot be distinguished from a peptic
stricture, graded stepwise dilation is recommended.
• A peptic stricture is a smooth, concentric, fixed narrowing, most
commonly seen in the lower esophagus, which may occur in the
presence or absence of esophagitis.
• Schatzki ring is a diaphragm-like web located at the SCJ, usually
marks the proximal margin of a hiatal hernia, best detected on a
barium swallow as it may disappear with air insufflation at OGD.
• Similar to patients with peptic strictures, Schatzki rings may
present with recurrent symptoms requiring repeated dilation.

IEE:
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Eso biopsies to confirm diagnosis+medical management.
Both bougie &balloon dilation used.
The overall risk of perforation with esophageal dilation is <1%.
Postprocedural pain &mucosal lacerations are common.
Risk factors: younger age, multiple dilations, upper strictures&
inability to traverse the stricture with the endoscope.
Balloon pull-through technique described with success of 92%.
A consensus committee recommended that dilation be reserved for
patients who have a dominant esophageal stricture or ring&those
who remain symptomatic despite medical therapy.
Dilation should be performed cautiously with graded smallcaliber dilators, not exceeding a 18 mm.
Some recommend bougie dilation because EoE may involve the
entire esophagus, others have recommended TTS balloons for
dilation under direct Visualization.

Anastomotic strictures:
• Occur in 9-48% of patients after esophagectomy for EC.
• Diagnosis: dysphagia& the standard flexible esophagoscope
cannot be passed.
• Risk fctors: anastomotic leakage,ischemia, a stapled as opposed to
a hand-sewn anastomosis,gastric pull-up instead of colonic
interposition&medical comorbidities CVD & DM.
• Both bougie& balloon used, success up to 93% but high
recurrence rate &require frequent multiple sessions ( 2-9/ patient)
• Electrocautery needle-knife treatment used if resistant to dilation
• Although short strictures (<1 cm) respond to a single
electrocautery trt, longer strictures may require multiple sessions.
• Tissue remodeling with temporary placement of fully covered
self-expandible metal stents increasingly applied for the
management of these benign, refractory, esophageal strictures.

Radiation-induced strictures:
• Proximal esophageal strictures occur in 2- 16% after radiation for
head / neck or lung cancer.
• Majority are complex & need several sessions of bougie dilation.
• Adequate relief up to 84%.
• A combined antegrade-retrograde rendezvous approach described
in case series for the management of severe radiation-induced
strictures with complete occlusion of the proximal esophagus.

Refractory or recurrent stricture:
• Refractory: inability to successfully dilate the stricture to
diameter of 14 mm over 5 sessions at 2-week intervals
• Recurrent: inability to maintain a satisfactory luminal diameter
for 4 weeks once the target diameter of 14 mm achieved.
• Not include patients with inflammatory Strictures or those with
neuromuscular dysfunction.
• Options for management:
• 1.Steroid injection into refractory, benign strictures immediately
before or after dilation has been shown to increase the postdilation diameter
• 2. Temporary esophageal stent placement is an adjunct to dilation
in the management of patients with refractory, benign, esophageal
strictures.
• 3. Self-bougienage is another option for patients who require
multiple frequent dilations.

Achalasia dilation:
• Usually with 30 - 40 mm diam pneumatic balloon dilators,
generally over a wire under fluoroscopic guidance,although
nonfluoroscopically-guided dilation by using endoscopic
visualization alone has been reported.
• Short-term relief is favorable, but recurrence reported in 1/3 with
long-term resolution as low as 40- 50%.
• In One study a 3-year success rate of 88%, predominantly to the
use of larger balloons (35- 40mm).
• Pneumatic dilation with 30 mm balloons failed in 42% within 3/12
• The overall risk of perforation:3- 5%.
• The strategy of 30 mm followed by 35 mm dilation may be a safer.
• Endoscopic Botox inj: The symptomatic response is often short
lived, with >50% recurrence by 6 months.
• LHM: No significant different results with PBD.

Achalasia dilation:
• Before endoscopic trt, patients with achalasia should be informed
of all therapeutic options available.
• Symptomatic patients with achalasia who are good surgical
candidates should be given the option of either graded pneumatic
dilation or cardiomyotomy.
• Open surgical repair with myotomy of early recognized
endoscopic perforation offers outcomes similar to those of elective
open myotomy.
• LHM may not be technically feasible after an endoscopic
perforation.
• Pneumatic dilation can be performed safely in patients after a
failed myotomy,if failed may require esophagectomy.
• Botulinum toxin may be the preferred approach in patients who
are poor candidates for surgery, as pneumatic dilation is not
recommended in these high-risk surgical candidates.

Achalasia dilation:
• Peroral endoscopic myotomy (POEM) is a new endoscopic
procedure for achalasia.
• Involves the creation of a 2-cm long mucosal incision in the
esophagus, 14 cm proximal to (LES).
• A submucosal tunnel is then created from the incision to the LES
followed by dissection of the circular muscle fibers over the distal
7 cm of the esophagus &proximal 2 cm of the gastric cardia.
• The mucosal incision is then closed using endoscopic clips.
• The success rate is 94% more in non-tortous esophagus.

Contraindications & adverse events:
• The presence of an esophageal perforation is an absolute
contraindication to esophageal dilation.
• Dilation should be performed with caution in patients who have
had a recent, healed perforation or upper GI surgery.
• The main adverse events associated with dilation are
perforation, bleeding & aspiration.
• The perforation rate for esophageal strictures after dilation
ranges from 0.1- 0.4%, higher with complex strictures &
radiation-induced strictures.
• The perforation rate may be influenced by endoscopist
experience, 4 times > when performed <500 previous diagnostic
upper endoscopic examinations.

Perforation diagnosis:
• Perforation after esophageal dilation can be intraabdominal or
intrathoracic at the site of the stricture.
• Should be suspected if a patient develops severe or persistent
chest or abdominal pain, dyspnea, tachycardia, or fevers after
dilation.
• physical exam: may reveal subcutaneous crepitus of chest or neck.
• Although CXR may indicate a perforation, a normal onedoes not
exclude it& a water-soluble contrast esophagram or CECT of the
chest may be necessary to confirm it.
• The use of large-diameter covered metal stents&
expandable, retrievable plastic stents has been effective in the
management of perforation after dilation of benign & malignant
strictures.

Recommendations:
• 1. We recommend endoscopic dilation for patients with dysphagia
secondary to benign intrinsic strictures of the esophagus.
• 2. We recommend wire-guided dilation, preferably under fl
uoroscopic guidance, or TTS balloon dilation for complex
esophageal strictures.
• 3. We recommend antisecretory treatment in conjunction with
dilation to reduce the recurrence rate of peptic strictures.
• 4. We recommend that dilation for adult patients with EoE be
reserved for those who have a dominant esophageal stricture or
ring and those who remain symptomatic despite medical therapy.
• 5. We suggest adjunctive treatment with corticosteroid injection
into recurrent or refractory benign esophageal peptic strictures.
• 6. We suggest that esophageal stent placement be reserved for
refractory esophageal strictures that do not respond to sequential
dilation and/or steroid injection.

Recommendations:
• 7. We recommend that both endoscopic&surgical treatment
options for achalasia be discussed with the patient.
• In patients who opt for endoscopic management& are good
surgical candidates, we recommend pneumatic dilation with
large-caliber balloon dilators.
• 8. We recommend botulinum toxin injection for endoscopic
treatment of achalasia in patients who are poor candidates for
surgery or pneumatic dilation.

BO5Q1:
• Esophageal strictures least amenable for
dilation is:
• A. Peptic stricture.
• B. Anastomotic stricture.
• C. Extrinsic compresion.
• D. Achalasia.
• E. Esophageal SCC.

BO5Q2:
• The following esophageal strictures are
amenable for dilation except:
• A. Pill-induced stricture.
• B. Pseudo achalasia.
• D. schatzki ring.
• E. Esophageal adenocarcinoma.

BO5Q2:
• The following esophageal strictures are
• A.Pill-induced stricture.
• B. Pseudo achalasia.
• D. schatzki ring.
• E. Esophageal adenocarcinoma.

BO5Q3:
• The following esophageal strictures are not
• A. Nut cracker esophagus.
• B. Diffuse esophageal spasm.
• D. Scleroderma-induced.
• E. Pseudoachalasia.

BO5Q3:
• Prior to esophageal stricture dilation all can be
performed except:
• A. Retroflextion in the stomach.
• B. Esophageal biopsies if endoscopic features suggest
EoE.
• C. Esophageal biopsies for EoE if there is no obvious
cause of dysphagia.
• C. Esophageal biopsies if malignancy suspected.
• D. Esophageal biopsies in all strictures.
• E. Esophageal biopsies during the dilation session.

BO5Q4:
• In esophageal stricture dysphagia starts to
occur when the lumen diameter is less than:
• A. 15 mm.
• B. 20 mm.
• C. 13 mm.
• C. 12 mm.
• D. 10 mm.
• E. 9 mm.

BO5Q5:
• The risks for recurrence of peptic strictures
after endoscopic dilation include all except:
• A. Complex stricture.
• B. Untreated acid reflux.
• C. Undiagnosed EoE.
• D. Undiagnosed bile reflux.
• E.Non of the above .

BO5Q6:
• Esophageal strictures starts to be labeled as
complex when the diameter & the length start
to measure more than :
• A. 12*20 mm.
• B. 10* 20 mm.
• C. 20*20.
• D. 40*10 mm.
• E.18* 10 mm.

BO5Q6:
• Esophageal strictures starts to be labeled as
complex when the diameter & the length start
to measure more than:
• A. 12*20 mm.
• B. 10* 20 mm.
• C. 20*20.
• D. 40*10 mm.
• E.18* 10 mm.

BO5Q7:
• What are the esophageal strictures that are
more associated together:
• A. Peptic & achalsia.
• B. Peptic & malignant.
• C. EoE & Schatski.
• D. Peptic & Pill-induced.
• E. Malignant & pill-induced.

BO5Q8:
• The following action are recommended before
endoscopic esophageal dilation for strictures
except:
• A. Stoping warfarin.
• B. Stoping clopidogrel.
• C. Continuing aspirin.
• D. Bacterial endocarditis antibiotic prophylaxis.
• E. Six hours solid food fasting.

BO5Q9:
• The therapeutic option for refractory
esophageal strictures include all except:
• A. Endoscopic steroid injection.
• B. Stenting.
• C. Self dilation.
• D. Calcium channel blockers.
• E.None of the above.

BO5Q10:
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The endoscopic botox injection is ideal for:
A. Treatment naive patients.
B. Poor surgical candidates.
C. Those who refuse surgery.
D. Young persons.
E. patients who failed mytomy.

Git j club dysphagia endoscopy.

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