Methods of Treating Dysphagia Caused by Benign Esophageal Strictures Gerald W. Dryden, MD, and Stephen A. McClave, MD The basic techniques of esophageal dilation using Maloney, Savary, or through-the-scope balloon dilators are common prac- tice for most endoscopists, and suffice for most situations. However, certain clinical situations, such as complicated peptic or caustic strictures and difficult rings, may respond poorly to standard techniques. In those instances, several adjunctive tech- niques can be helpful at increasing the chances of achieving symptomatic relief. The endoscopist who has a good working knowledge of the principles of dilation coupled with knowledge of these adjunctive techniques will increase the overall success in treating difficult cases of dysphagia. Copyright @ 2001 by W.B. Saunders Company D Ysphagia, a common symptom stemming from a wide range of benign esophageal diseases, is treated with a variety of dilation techniques. The principles for dilating all types of esophageal strictures are similar, and a physician armed with the basic techniques of esophageal dilation should be adept at eliminating dysphagia caused by most lesions. The three types of dilators used in standard dilation techniques include mercury-filled Maloney dilators, Savary guidewire-based dilators, and through-the-scope (TTS) bal- loon dilators. For simple strictures and rings, the common practice of us- ing Maloney dilators passed with or without fluoroscopy should suffice. Complex strictures usually require wire-guided Savary or TTS balloon dilators. However, standard dilation techniques do not ensure success in all cases. This is particu- larly true in the case of severe peptic or caustic strictures. The patient presumed to have complex strictures may benefit from undergoing a minimal radiographic evaluation (to evaluate the cause of dysphagia and the complexity of the stricture) per- formed before endoscopy to enhance the management and choice of dilating techniques. Addition of the adjunctive tech- niques covered in this review should help to eliminate dyspha- gia refractory to standard treatments in the patient with com- plex stricture, aiding the physician in providing relief for all patients. From the Division of Gastroenterology/Hepatology,University of Lou- isville School of Medicine, Louisville, KY. Address reprint requests to Gerald W. Dryden, MD, Division of Gas- troenterology/Hepatology, University of Louisville School of Medicine, 550 S Jackson St, Louisville, KY 40292. Copyright 9 2001 by W.B. Saunders Company 1096-2883/01/0303-0003535.00/0 doi:10.1053/tgie.2001.24012 Benign Etiologies of Dysphagia When considering benign etiologies, the differential diagnosis of a focal stenosis in the esophagus on barium swallow includes a muscular ring, achalasia, peptic stricture, esophageal web, and Schatzki's ring. ~ In addition, rare cases of esophageal leiomyoma, nenroma, aberrant vascular structures, and con- genital cartilaginous remnants have also been reported to have similar radiographic appearances. 2 Peptic strictures are the most common etiology of dyspha- gia, accounting for approximately 80% of benign esophageal strictures. Stricture formation begins as an inflammatory process, with edema and inflammatory cell infiltrate on mi- croscopic examination. This eventually leads to disposition of connective tissue and collagen, culminating in fibrosis. The initial luminal narrowing results primarily from edema and muscle spasm, and is reversible with acid control. How- ever, progressive tissue damage and fibrosis from continued reflux results in the formation of a peptic stricture) Other factors contributing to peptic stricture formation include those factors that contribute to gastroesophageal reflux dis- ease (GERD) (scleroderma, hypotensive lower esophageal sphincter, weak peristalsis, hypersecretion of acid, and in- creased gastric volume), nasogastric tube placement, and chemical injury (alkaline, acid or nonsteroidal anti-inflam- matory drug [NSAID]-induced damage). Peptic strictures usually present as progressive solid food dysphagia, often in the setting of chronic GERD symptoms. Uncomplicated pep- tic strictures may be defined by a short length, lack of tortu- osity, and luminal diameter greater than 36F 3 (Table 1). The lower esophageal ring (Schatzki's ring or B ring) or web accounts for about 4% to t0% of benign esophageal strictures. 4 The pathophysiology of an esophageal ring is not as clear as for a peptic stricture, although several reports suggest acid reflux and esophagitis play some role in the genesis of these lesions. 5,6 Lower esophageal rings over time may progress to more closely resemble a peptic stricture, with certain medications (such as vitamin C, ferrous sulfate, quinine, etc) playing a role in that evolution. 7 Often, rings are found in asymptomatic patients. The threshold for pro- ducing symptoms correlates with a luminal narrowing of less than 13 mm. s A Schatzki's-type B ring nearly always occurs above a hiatal hernia at the level of the true gastroesophageal junction. It tends to be very thin with a fixed diameter, and may have associated evidence of esophagitis. Patients usu- ally complain of intermittent solid food dysphagia. Develop- ing symptoms from food bolus impaction in the esophagus for the first time while dining out constitutes the "steak- house syndrome." Documentation of a web in the setting of iron deficiency anemia constitutes the Plummer Vincent Techniques in Gastrointestinal Endoscopy, Vol 3, No 3 (July), 2001: pp 135-143 135