American Gastroenterological Association medical position statement on treatment of patients with dysphagia caused by benign disorders of the distal esophagus☆

Article Outline

• Abstract
• Peptic esophageal strictures
• Lower esophageal mucosal ring
• Achalasia
• Copyright

Abstract 

This document presents the official recommendations of the American Gastroenterological Association (AGA) on treatment of patients with dysphagia caused by benign disorders of the distal espophagus. It was approved by the Clinical Practice and Practice Economics Committee on September 27, 1998, and by the AGA Governing Board on November 8, 1998.

GASTROENTEROLOGY 1999;117:229-232

A general approach to the treatment of adult patients who have dysphagia caused by benign disorders of the distal esophagus is outlined in Algorithm 1.

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• Algorithm 1. Management of dysphagia.

Historical features strongly suggesting that dysphagia is caused by a disorder of the distal esophagus include the patient's perception that swallowed material sticks at a level below the suprasternal notch and the absence of oropharyngeal symptoms (difficulty in initiation of swallowing, swallowing accompanied by nasopharyngeal regurgitation, pulmonary aspiration, and a sensation that residual material remains in the pharynx).

A barium swallow may be indicated before endoscopy if the clinical suspicion is high for achalasia; it can be difficult to recognize achalasia by endoscopy alone, especially in early cases. If the history, barium swallow, or both suggest achalasia, manometry to confirm the diagnosis usually should precede endoscopic evaluation so that the clinician can be prepared to perform endoscopic therapy for the disorder. A barium swallow also may be warranted before endoscopic examination if the history suggests the possibility of a lesion that might pose a hazard for endoscopy such as a Zenker's diverticulum or a proximal esophageal tumor. If such a lesion is found, the forewarned endoscopist can take appropriate precautions in passing the endoscope.

Reflux esophagitis occasionally causes dysphagia, even in the absence of peptic stricture. After initial endoscopic evaluations that document reflux esophagitis without stenosis, patients whose esophagitis and dysphagia resolve with antireflux therapy require no further tests. Esophageal manometry is recommended for patients whose dysphagia persists despite adequate antireflux therapy (with healing of esophagitis documented endoscopically).

For patients with no lesion demonstrable by barium swallow and endoscopy, limited data suggest that a trial of empiric abrupt dilation (identical to that recommended for treatment of lower esophageal mucosal rings) is safe and reasonably effective. Patients who respond to empiric dilation presumably have subtle rings, webs, or strictures that are missed by diagnostic studies. Esophageal manometry is recommended for patients whose dysphagia persists despite empiric dilation after adequate endoscopic examination has been done.

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Peptic esophageal strictures 

Management of peptic esophageal stricture begins with assessment of whether the stricture is complicated by a small diameter or tortuosity (Algorithm 2).

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• Algorithm 2. Management of peptic esophageal stricture.

Mercury-filled bougies with diameters less than 10 mm (30F) are so floppy that they tend to curl in the esophagus rather than to traverse complicated strictures. Therefore, guided dilation using polyvinyl bougies or balloons is recommended for tight or tortuous strictures. Simple strictures can be dilated with mercury-filled dilators. The choice among dilator types should be based on the availability of the dilators in a given institution and on the operator's experience and comfort in using them because published experience has not convincingly established the superiority of one dilator type over another.

Esophageal strictures are dilated progressively rather than abruptly. If dilation is performed with bougies, the first bougie passed should have a diameter approximately equal to that estimated for the stricture. Bougies of progressively increasing diameter are introduced until resistance is first encountered, after which no more than two additional bougies are passed during any one session. If balloon dilators are used, the initial dilation usually should be limited to a diameter of no more than 45F. The extent of initial stricture dilation does not seem to influence either stricture recurrence or the requirement for subsequent dilation, so there is little support for the concept that strictures should be dilated aggressively to prevent recurrence. The extent of dilation in an individual patient should be based on the symptomatic response to therapy and on the difficulties encountered during the dilation procedure. Most patients experience good relief of dysphagia with dilation to a diameter between 40F and 54F. Strictures generally should not be dilated to a diameter beyond 60F.

Aggressive antireflux therapy with proton pump inhibitors or fundoplication improves dysphagia and decreases the need for subsequent esophageal dilations in patients with peptic esophageal strictures. For patients whose dysphagia persists or returns after an initial trial of dilation and antireflux therapy, healing of reflux esophagitis should be confirmed endoscopically before dilation is repeated. When healing of reflux esophagitis has been effected, the need for subsequent dilations is determined empirically. For patients whose dysphagia persists or returns quickly despite adequate control of reflux esophagitis, a trial of steroid injection of the stricture can be considered. Patients who experience only short-lived relief of dysphagia after dilation can be taught the technique of self-bougienage. Rarely, truly refractory strictures require esophageal resection and reconstruction.

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Lower esophageal mucosal ring 

Dilation therapy for lower esophageal mucosal rings involves the passage of a single large bougie or balloon (45–60F) aimed at fracturing (rather than merely stretching) the rings (Algorithm 3).

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• Algorithm 3. Management of lower esophageal mucosal ring.

After abrupt dilation, any associated reflux esophagitis is treated aggressively. The need for subsequent dilations is determined empirically. However, recurrence of dysphagia is likely, and patients should be advised that repeated dilation probably will be needed in the future. Esophageal manometry is recommended for patients whose dysphagia persists or returns quickly despite adequate dilation and antireflux therapy. For patients with a treatable motility disorder such as achalasia, therapy is directed at the motility problem. If no treatable motility disorder is found, endoscopy is repeated to confirm that esophagitis has healed and that the ring has been disrupted. For patients with persistent rings, another trial of abrupt dilation usually is warranted. Refractory rings that do not respond to abrupt dilation using standard balloons and bougies may respond to pneumatic dilation with large balloons (those used to treat achalasia), endoscopic electrosurgical incision, and surgical resection. These therapies should be required only rarely for patients with lower esophageal mucosal rings, and only after other causes of dysphagia have been excluded.

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Achalasia 

The diagnosis of pseudoachalasia caused by malignancy should be excluded before invasive therapies such as pneumatic dilation or surgical myotomy are implemented. This usually can be accomplished with a careful history and endoscopic examination, although computed tomography and endosonography may be necessary to exclude an infiltrating neoplasm in some cases. Patients with primary achalasia who are good operative risks should be treated with either pneumatic dilation or surgical myotomy (Algorithm 4).

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• Algorithm 4. Management of achalasia.

Surgery appears to be somewhat superior to pneumatic dilation for both the short-term and long-term relief of dysphagia, and the mortality rates for the two procedures are approximately equal. The major disadvantages for surgery are the high initial cost, the protracted recovery period, and the frequent development of gastroesophageal reflux disease postoperatively. Long-term results are not yet available for myotomy performed using minimally invasive techniques, but the short-term results are promising. Presently, the decision between pneumatic dilation and myotomy as initial therapy for achalasia should be based on a consideration of the patient's preferences, age, and clinical status and on the availability of personnel experienced in the two techniques.

After successful pneumatic dilation, the reappearance of dysphagia suggests either a return of tone in the damaged lower esophageal sphincter muscle or the development of reflux esophagitis with peptic stricture formation. Endoscopic examination usually can differentiate these disorders readily, although manometry occasionally may be required to make this distinction in equivocal cases. Esophagitis is treated with antireflux therapy, and peptic strictures are treated as shown in Algorithm 2. If endoscopy shows return of muscle tone in achalasia, the pneumatic dilation is repeated using a larger balloon. Generally, pneumatic dilation should not be repeated more than three times. Patients with persistent or recurrent dysphagia caused by achalasia after three pneumatic dilations should be treated with surgical myotomy.

Patients who represent poor operative risks can be given a trial of medical therapy with nitrates or calcium channel blockers. If these agents are ineffective or poorly tolerated, a trial of abrupt bougienage using a 45–60F dilator can be considered. Botulinum toxin injection of the lower esophageal sphincter can be used for patients whose symptoms do not respond to medical therapy or bougienage. It is also acceptable to use botulinum toxin injection as initial therapy for patients who represent poor surgical risks if the clinician judges that medications and bougienage would be poorly tolerated. Botulinum toxin injection appears to be a safe procedure that can induce a clinical remission for at least 6 months in approximately two thirds of patients with achalasia. However, most patients will need repeated injections to maintain the remission, and only approximately two thirds of patients in remission at 6 months will remain in remission at 1 year, despite repeated injections. When these treatments have failed, the physician and patient must decide whether the potential benefits of pneumatic dilation or myotomy outweigh the substantial risks that these procedures pose for elderly or infirm patients. A feeding gastrostomy is a safer alternative than pneumatic dilation or myotomy, but many neurologically intact patients find life with a gastrostomy unacceptable.

This medical position statement has been endorsed in principle by the American Association for the Study of Liver Disease, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy.