GUIDELINE Esophageal dilation This is one of a series of statements discussing the use of gastrointestinal endoscopy in common clinical situa- tions.The Standards of Practice Committee of the Amer- ican Society for Gastrointestinal Endoscopy prepared this text.In preparing this guideline, a MEDLINE literature search was performed, and additionalreferences were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective tri- als, emphasis is given to results from large series and re- ports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert con- sensus.Further controlled clinicalstudiesare needed to clarify aspectsof this statement, and revision may be necessary asnew data appear.Clinical consider- ation may justify a course of action at variance to these recommendations. INTRODUCTION The purpose ofthis updated guideline is to provide practical recommendations regarding the indications and techniques for the use of esophageal dilation. Esophageal dilation (EGD) is performed for treatment of documented anatomic,and sometimes functional,narrowing ofthe esophagus caused by a variety of benign and malignant conditions. 1 The formation ofbenign strictures of the esophagus is believed to be caused by the production of fibrous tissue and deposition of collagen stimulated by deep esophageal ulceration orchronic inflammation. 1 The most common form ofan esophageal stricture,a peptic stricture, is a sequela of reflux esophagitis. In the recent past, nearly 80% of strictures were due to gastro- esophageal reflux, 2 although this may be decreasing with the widespread use ofproton pump inhibitors(PPIs). Other common benign causes include Schatzki’s ring, ra- diation therapy, congenitalstrictures,caustic ingestion, and anastomotic strictures. Less common causes of benign esophageal strictures include those following endoscopic therapy of varices, photodynamic therapy (PDT), 1 reaction to a foreign bodyor pill, infectiousesophagitis, and eosinophilicesophagitis(Table 1). Narrowingof the esophagus from malignancy may result either from intrin sic luminaltumorgrowth or from extrinsic esophageal compression. During the endoscopicevaluation ofan esophageal stricture,biopsy specimens should be taken to exclude malignancy when this diagnosis is suspected on the basis of clinical presentation or endoscopic appear ance.In young patients with dysphagia with or without endoscopicabnormalities, especiallywith a history of food impaction, midesophageal biopsy specimens should be obtained to exclude eosinophilic esophagitis. 3 Endo- scopic esophageal biopsy samples can be safely obtained before esophageal dilation. 4 Patients with an esophageal stricture characteristically have dysphagia to solids and generally have no difficulty swallowing liquids, in contrast to those with an esopha- gealmotility disorder in which liquid and solid dysphagia occurs. 1 Symptoms in the latter group of patientsare generally notimproved with esophageal dilation,with achalasia being the most notable exception. EOSINOPHILIC ESOPHAGITIS Eosinophilic esophagitisdeservesspecial mention because it is becoming increasingly common, 5 there is avail- able therapy in addition to dilation, 6 there are recognizable endoscopic 7-9 and histologic features, 10 and there appears to be an increased risk for mucosal tearing during endos- copy. 11 The latter may translate into an increased risk perf ration during dilation. 12 Eosinophilic esophagitis is common in young patients with otherwise unexplained dysphagia. clinical presentation of food impaction is not uncommon. 13 INDICATIONS FOR DILATION The primary indication for esophageal dilation is to re- lieve dysphagia. Cost analysis evaluations have suggested that initial EGD with therapeutic intent is less costly than a barium swallow in patients with a history suggesting esophageal obstruction. 14 Additionally, early endoscopy should be the initial diagnostic test performed in patients with dysphagia who are R40 years old and those with con comitant heartburn, odynophagia, or weight loss because the high yield offinding significant pathology in these patients. 15 Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.02.031 www.giejournal.org Volume 63, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 755