Guideline: The role of endoscopy in the evaluation& management of dysphagia .

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: • 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&malignantconditions. • Benign inflammatory strictures result from collagen&fibroustissue 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,diffuseesophageal 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 EoEbut without obvious esophageal mechanical obstruction. • Mucosal biopsies performed in conjunction with dilation do not appear to confer any additional risk for perforation. • Retroflexionof 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,completionof 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&AmericanConMed, 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,canbe used without sedation, may be used for self-dilation by select patients. • These dilators should not be used for narrow,complexstrictures because of the possibility that they could buckle above the stricture & result in perforation.

Type of eso dilators: • 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 impregnatedwith 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 cannulationof severe strictures.

Type of eso dilators: • Bougiedilators exert both radial&axialforces 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 intakeof 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. • Moderatesedation for dilation in the majority of patients& deep sedation or general anesthesia may be required for complex procedures or significant comorbidities.

Patient preparation: • 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.

Patient preparation: • All necessary equipmentshould 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, needleknifepapillotome, 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 >3consecutive 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.

Schatzkiring: • Dilation with a single, large (16 -20 mm) dilator leads to rupture of the Schatzkiring&symptomatic relief in almost all patients. • Adjunctive methods: electrocauteryincision with needle-knife papillotome& 4-quadrant biopsies of the ring BZ of association between EoE&Schatzkiring& 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. • Apeptic stricture is a smooth, concentric, fixed narrowing, most commonly seen in the lower esophagus, which may occur in the presence or absence of esophagitis. • Schatzkiring 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, Schatzkirings may present with recurrent symptoms requiring repeated dilation.

IEE: • Eso biopsies to confirm diagnosis+medicalmanagement. • Both bougie&balloon dilation used. • The overall risk of perforation with esophageal dilation is <1%. • Postproceduralpain &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&thosewho remain symptomatic despite medical therapy. • Dilation should be performed cautiously with graded small-caliber dilators, not exceeding a 18 mm. • Some recommend bougiedilation because EoEmay 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,gastricpull-up instead of colonic interposition&medical comorbidities CVD & DM. • Both bougie&balloon used,success up to 93% but high recurrence rate &requirefrequent multiple sessions ( 2-9/ patient) • Electrocauteryneedle-knife treatment used if resistant to dilation • Although short strictures (<1 cm) respond to a single electrocauterytrt, 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-inducedstrictures: • Proximal esophageal strictures occur in 2-16% after radiation for head / neck or lung cancer. • Majority are complex & need several sessions of bougiedilation. • 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 thosewith neuromuscular dysfunction. • Options for management: • 1.Steroid injection into refractory, benign strictures immediately before or after dilation has been shown to increase the post-dilation 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,althoughnonfluoroscopically-guided dilation by using endoscopic visualization alone has been reported. • Short-term relief is favorable, but recurrence reportedin 1/3 withlong-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. • Botulinumtoxin 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 forachalasia. • 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 fibersover 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. • Dilationshould 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 endoscopistexperience, 4 times > when performed <500 previous diagnostic upper endoscopic examinations.

Perforation diagnosis: • Perforation after esophageal dilation can be intraabdominalor 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 onedoesnot 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 fluoroscopic 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 EoEbe 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. • C. Extrinsic compresion. • D. schatzki ring. • E. Esophageal adenocarcinoma.

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

BO5Q3: • The following esophageal strictures are not amenable for dilation except: • A. Nut cracker esophagus. • B. Diffuse esophageal spasm. • C. Extrinsic compresion. • 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. Stopingclopidogrel. • C.Continuing aspirin. • D. Bacterial endocarditis antibiotic prophylaxis. • E. Six hours solid food fasting.

Guideline: The role of endoscopy in the evaluation& management of dysphagia .