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home - Oesophagus - Dysphagia - Dilatation Written by Dr Sebastian Zeki

Knows the various causes of dysphagia and their clinical

Understands the methods of assessment and investigation including
the use of manometric assessment where appropriate

Knows the range of therapeutic options including the potential for
endoscopic treatment, and how to select appropriate treatment

Non-Cardiac Chest Pain:
Understands the potential role of the oesophagus in patients
presenting with chest pain in whom a cardiac cause has been
excluded and its role in the genesis of functional symptoms.

Knows the range of appropriate investigation of such patients and the
various avenues of management

Carcinoma of the Oesophagus:
Knows the predisposing factors, presentation, diagnostic work-up and

Knows the range of potential therapies (including palliative care), and
understand how the appropriate selection is made

Can make a thorough clinical assessment, select investigations
appropriately and plan therapy.

Manages patients with oesophageal disease with care and



Stricture dilation The overall perforation rate: 0.1 % per session Risk factors -Malignant stricture -Severeoesophagitis -Prior radiation therapy -A history of caustic ingestion -Eosinophilicoesophagitis -Complex (tortuous) or long strictures -Presence ofoesophageal diverticula -Inexperienced operator -A large hiatal hernia -Use of high inflation pressures with balloon dilation -A history of previousoesophageal perforation -A history of prioroesophageal surgery (such as for trauma or a congenital abnormality) Chest pain Pain can happen during dilatation. If suspect a perforation, then keep in for observation and barium swallow prior to discharge Haemorrhage Blood transfusions needed in 0.2 % ofoesophageal dilations with mechanical dilators, and 2% with balloon dilation. Bacteraemia- 45% No need for prophylac - tic antibiotics Contraindications To Dilatation Consider specific features of oesophageal stricture acute or incompletely healedoesophageal perforation. Caution if pharyngeal or cervical deformity, recent surgery, a large thoracic aneurysm, or an impacted food bolus. Endpoint Of Dilatation At18 mm (54 French) allows intake of a regular diet unless there is a coexisting motility disturbance. At 45 French (15 mm) are able to eat a modified regular diet. < 13 mm (39 French) will usually experience solid food dysphagia Refractory Strictures Self-dilation Motivated patients with simple strictures benefit from a schedule of regular self-dilation with a Maloney dilator. Intralesional Steroids Intralesional 0.2 mL of triamcinolone acetonide into all four quadrants .-impedes collagen deposition and enhance its breakdown locally, thereby reducing scar formation Can be combined with oral steroids Nonmetal stents Nonmetal expandable stents can be effective in management of refractory benign strictures- effective in 40% Other methods Electrosurgical incision of peptic and postoperative strictures and Schatzki's rings. Mitomycin C has been used in a case report Technique No > three dilators of progressively increasing diameter should be passed in a single session Luminal stenosis should be increased by no > 2 mm (6 French). For very tight or for long strictures, only one or two dilators is passed at each session. Complications Cervical perforation Neck pain Tenderness of the SCM, Dysphonia, hoarseness, Cervical subcutaneous emphysema. Intrathoracic perforation Chest, back, or epigastric pain, which is exacerbated with inspiration and swallowing. Dysphagia, odynophagia, dyspnea, hematemesis and cyanosis. Pericardial tamponade (rare) if posterior pericardium perf. Hammans sign (auscultatory crunch with mediastinal emphysema) Hoarse Clinical manifestations Diagnosis 1. CXR- (95% positive in cervical and 40% thoracic perf.) Pneumomediastinum or Density adjacent to the descending aorta in the left cardiophrenic angle resulting in loss of contour of the descending aorta in 2. Barium in left lateral position more sensitive 3. CT even better Perforation No screening Peptic strictures Screening Complex strictures Long, narrow, or tortuous, anatomically complicated Balloon dilators 1.Through-the-scope dilator (down the biopsy channel) 2. Over-the-guidewire balloon dilator. Initial balloon size corresponds to the estimated stricture diameter : A 10 mm balloon for diameters 2 -4 mm A 12 mm balloon for diameters 5 -9 mm A 15 mm balloon for a diameter >9 mm Dilate over 30-60 seconds Mechanical dilators Types of dilators No guidewire: 1. The Maloney (common, no guidewire needed) 2. Hurst -rounded tip, which is more difficult to pass, and is rarely used. Guidewire assissted dilators: 1. Savary-Gilliard- most common 2. American Dilatation System 3. Eder-Puestow olive dilators Diameter of the initial dilator should be the same width as the stricture. Technique Treatment: Criteria for selecting patients for nonsurgical management: -Containment of perforation within neck/ mediastinum with no thoracic / peritoneal/ pleural extension. -No preexisting oesophageal conditions with distal obstruction. -Not systemically unwell. Medical management -Avoidance of all oral intake for 10 to 14 days -TPN -IVs broad spectrum antibiotics (eg, ticarcillin-clavulanate) -Drainage of fluid collections -No NG tube -If deteriorate clinically, then for surgery -Repeat contrast after 10 to 14 days Written by Dr Sebastian Zeki

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