Synopsis
Differentiate a reflux-related fibrotic stricture from a mucosal ring and malignancy, obtain appropriate biopsies, and combine safe dilation with treatment of the underlying mucosal disease.
- Peptic strictures usually lie distally after chronic reflux injury and cause gradually progressive solid-food dysphagia.
- A Schatzki ring is a thin mucosal ring at the squamocolumnar junction and often causes intermittent dysphagia to bread or meat.
- Biopsy every stricture before dilation where safely possible to exclude malignancy and eosinophilic oesophagitis.
Key red flags
Progressive dysphagia, weight loss, anaemia or an irregular stricture requires urgent biopsy for malignancy.
Severe pain, tachycardia, dyspnoea, fever or crepitus after dilation suggests perforation and needs emergency imaging and surgical input.
Rapid progression, weight loss, bleeding or an irregular shouldered lesion requires tissue diagnosis before a benign label.
Investigation priorities
Diagnose the narrowing and exclude malignant or eosinophilic causes.
Management branches
Biopsy confirms benign reflux-related fibrosis and the patient cannot tolerate normal solids.
- Explain graded dilation, likely need for more than one session, perforation risk and the importance of acid control.
- Use a wire-guided bougie or through-the-scope balloon along a known path and plan cautious serial sessions for a tight or complex stricture rather than forcing a large increase in one session.
Key medicines
Omeprazole after peptic-stricture dilationAfter dilation of a reflux-mediated peptic stricture, continue long-term full-dose omeprazole: 20 mg orally once daily is the usual full dose, while 40 mg once daily is the severe-oesophagitis full dose after an eight-week healing course. This post-dilation indication should not be reduced automatically to intermittent or on-demand therapy.Swallow the gastro-resistant tablet whole with water and do not chew or crush it. Nelfinavir is contraindicated and concomitant clopidogrel is discouraged; hepatic impairment may require a lower dose. During prolonged therapy, periodically review the continuing indication and individual risk of hypomagnesaemia, reduced vitamin B12 absorption, enteric infection and fracture; investigate or monitor according to symptoms and risk factors rather than ordering every test for everyone or stopping indicated post-dilation maintenance automatically. Reassess recurrent dysphagia for restricture, malignancy or eosinophilic disease. A PPI may itself induce remission in eosinophilic oesophagitis, but response requires disease-specific clinical and histological assessment.