Paraoesophageal Hernia

An oesophageal stricture is pathological narrowing of the oesophageal lumen producing impaired passage of food.

Benign causes include chronic acid reflux, postoperative anastomotic scarring, radiation injury, eosinophilic oesophagitis and caustic injury.

Malignancy must be excluded before a new stricture is labelled benign.

Strictures are clinically described as simple or complex. Simple strictures are short, straight and permit passage of a standard endoscope. Complex strictures are long, irregular, severely narrowed or angulated and carry a higher dilation failure and perforation risk.

Progressive solid food dysphagia is typical.

With increasing narrowing, dysphagia progresses to semisolids and eventually liquids.

Food bolus impaction may be the first presentation.

Weight loss, rapidly progressive dysphagia, anaemia or odynophagia should raise concern for malignancy.

Peptic strictures are typically distal and occur in patients with longstanding reflux. Anastomotic strictures occur after oesophageal or gastric surgery.

Upper gastrointestinal endoscopy with biopsy: establishes the site and character of the narrowing and excludes malignancy before definitive dilation.

Contrast swallow: useful for very tight, long, tortuous or complex strictures and when the endoscope cannot safely traverse the narrowing.

Biopsy apparently benign strictures when malignancy has not been confidently excluded.

Treat both the narrowing and its underlying cause.

Endoscopic dilation is first line for most benign strictures.

Either wire guided bougie dilation or through the scope balloon dilation is appropriate. Select according to length, configuration and operator expertise. Complex strictures should undergo wire guided or fluoroscopically assisted dilation rather than blind bougienage.

Dilation should be progressive rather than aggressive. Increase diameter in controlled steps according to stricture resistance and anatomy. Modern practice commonly uses two or three incremental increases during a session rather than attempting immediate normal calibre.

A luminal diameter around 15 mm is sufficient for comfortable swallowing in many patients, although some require approximately 16 to 18 mm depending on anatomy and recurrence.

For a peptic stricture, use potent acid suppression after dilation:

Omeprazole 40 mg orally once daily, increasing to 40 mg twice daily when reflux remains inadequately controlled.

Recurrent reflux despite correctly administered proton pump inhibitor therapy may justify antireflux surgery after the stricture has been adequately assessed and dilated.

A refractory benign stricture is generally considered one that cannot be successfully maintained at an adequate swallowing diameter despite repeated appropriately performed dilation.

For selected recurrent peptic or anastomotic strictures, intralesional corticosteroid can reduce recurrence:

Triamcinolone 40 mg/mL, 0.5 mL injected into each of four quadrants, usually into the stricture immediately before or after dilation according to technique.

Refractory disease may require endoscopic incisional therapy, temporary fully covered stenting or surgical reconstruction.

Sudden severe chest pain, tachycardia, dyspnoea or subcutaneous emphysema after dilation requires immediate evaluation for oesophageal perforation.