BENIGN (PEPTIC) STRICTURE Group D Mamba - Medenilla.
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Transcript of BENIGN (PEPTIC) STRICTURE Group D Mamba - Medenilla.
BENIGN (PEPTIC)
STRICTURE
Group DMamba - Medenilla
BENIGN (PEPTIC) STRICTURE
• Peptic Stricture– Results from fibrosis that causes luminal
constriction
Source:p.1851
According to size Caused byShort strictures(usually 1-3cm long)
spontaneous reflux
Long, tubular peptic strictures
• persistent vomiting • prolonged nasogastric intubation.
BENIGN (PEPTIC) STRICTURE
Clinical features
Diagnosis
General principles of Treatment
Clinical features
Source:p.1851
BENIGN (PEPTIC) STRICTUREClinical features
Patient Benign Peptic Stricture• History
– Difficulty of swallowing– Regurgitation of sour material– Chest pain after eating– Copious sputum upon waking up– Dysphagia to solid foods– Occasional vomiting of previously
taken in food– Symptoms relieved by Omeprazole
but would recur intermittently– Weight loss of 8 kg
• History– Progressive dysphagia
to solid food– Heartburn and chest
pain– Odynophagia– Food impaction– Weight loss
Esophageal stricture, http://emedicine.medscape.com/
BENIGN (PEPTIC) STRICTUREClinical features
Patient Benign Peptic Stricture
• Physical exam– BMI: 17.63 kg/m^2– Vital signs normal– Pulmonary: No crackles nor
wheezes– Cardiac: Heart sounds
unremarkable– Abdominal: scaphoid
abdomen, non tender, no masses
– Neurologic: no evident deficit
• Physical exam– Physical examination
frequently does not provide clues to the cause of dysphagia.
– Assess nutritional status
Esophageal stricture, http://emedicine.medscape.com/
BENIGN (PEPTIC) STRICTURE
Clinical features
Diagnosis
General principles of Treatment
Diagnosis
Source:p.1851
1. History2. Therapeutic Trial
with a PPI (eg omeprazole, 40 mg BID for 1 wk)
Barium swallow
Barium swallow showing peptic stricture due toGastro-esophageal reflux
Upper Endoscopy / EGD
• 8-hour fasting, Flexible scope is advanced under direct vision into upper GIT
• Alarm Symptoms that indicate the need for EGD– Weight loss, Recurrent vomiting, Dysphagia,
Bleeding, Anemia
• Most serious complications of EGD: perforation, aspiration, respiratory depression from excessive sedation
Barium Esophagram
• Provides objective baseline information: – location, length– stricture diameter– esophageal wall consistency– irregularity
• Complementary to endoscopic findings• May be more sensitive than endoscopy for detection
of subtle narrowings of the esophagus• 100% sensitivity with luminal diameter <9 mm• 90% sensitivity with luminal diameter >10 mm
24-Hour pH Monitoring
• Identifies the presence and extent of reflux• Helpful in evaluating and documenting the
adequacy of therapy in patients who remain symptomatic despite treatment with PPIs or fundoplication
BENIGN (PEPTIC) STRICTURE
Clinical features
Diagnosis
General principles of Treatment
General principles of Treatment
• For patients [with GERD] + associated peptic stricture
Source:p.1852
GOAL TREATMENT
To relieve dysphagia Endoscopic dilation
To relieve reflux Vigorous treatment of GERD Anti-secretory agents Anti-reflux surgery Lifestyle modification
*To improve nutritional status *Diet control
Medical Care
• Several studies have demonstrated that aggressive acid suppression using PPIs is extremely beneficial in:
initial treatment long-term management
PPI’s for aggressive acid-suppression
• Improve esophagitis• Decrease the need for subsequent esophageal
dilatation
• PPI therapy has to be individualized– depending on the level of reduction in acid
exposure as assessed by 24-hour pH monitoring.
PPI’sOmeprazole (Prilosec)
Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump.
Adult : 20 mg PO qam 30 min ac; may increase bid
Lansoprazole (Prevacid)Suppresses gastric acid secretion by specifically inhibiting H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.
Adult : 30 mg PO qam 30 min ac; may increase to 30 mg bid
Rabeprazole (Aciphex)Decreases gastric acid secretion by inhibiting the parietal cell
H+/K+ ATP pump.Adult :20 mg PO qam 30 min ac; may increase to 20 mg
PO bid if necessary
PPI’sPantoprazole (Protonix)
Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump.
Adult : 40 mg PO qam 30 min ac; may increase to bid
Esomeprazole magnesium (Nexium)S-isomer of omeprazole. Inhibits gastric acid
secretion by inhibiting H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cells.
Adult : 20-40 mg PO qd for 4-8 wk
Surgical Care (endoscopic and surgical modalities )
• choice of dilator and technique is dependent on many factors, the most important being stricture characteristics
• factors, including patient tolerance, operator preference, and experience.
• Dilatation therapy should be tailored individually
Endoscopic Therapy
– Usually the physician passes a series of dilators or gradually increases the diameter of the balloon to stretch out the stricture.
– Complications : ~0.5% of all esophageal dilation procedures
• Perforation• Bleeding
Surgical Therapy
• Classic fundoplication– long-term success rate ranging from 65 to 90%.
• Laparoscopic approach report a 12% failure rate, whereas others demonstrate significantly higher recurrence rates (25%).
• Esophageal lengthening gastroplasty of the Collies-Nissen type or Collies-Belsey Mark IV type have been proposed
Specific Treatment Plan for the PatientTHERAPY REQUEST FOR/PRESCRIBEEndoscopic Endoscopic Balloon DilationSurgical FundoplicationPharmacologic Double Dose PPI -
(Omeprazole 40mg PO qam 30 minutes ac)
Non-Pharmacologic Lifestyle change(esp. cessation of smoking)Diet Modification
Thank you!