GERD and Refractory Reflux: GERD and Refractory Reflux: Strictures and Rings

0:00Welcome to Board Pearls. This is episode three of three of the GERD and Refractory Reflux chapter, in the Esophageal Disorders module. This episode is the reflux patient whose food has started to stick, through two patients. A seventy-one-year-old woman with decades of untreated heartburn has a peptic stricture. Her case teaches how the pattern of her dysphagia points to the diagnosis before any test, why her improving heartburn is a warning rather than good news, what her endoscopy must do besides look, how a scarred narrowing is opened without tearing it, and what keeps it open. A thirty-six-year-old man with intermittent steak impactions has a Schatzki ring. His case teaches how a fixed ring is told apart from a tightening stricture, and why it's treated in the opposite way.

0:44Here's the first patient. A seventy-one-year-old woman has had heartburn for twenty years and has never taken anything for it regularly. Over the past six months, solid food has started sticking low in her chest: first meat, then bread, and now even rice. Last week a piece of chicken stuck until she vomited it back up. Liquids go down fine. Oddly, she says, her heartburn has been better lately. She hasn't lost weight.

1:11The pattern of her dysphagia points to the diagnosis before any test. Solids only, with liquids going down normally, is the structural pattern: something is narrowing the lumen, so only a bolus bigger than the opening hangs up. And hers is getting steadily worse, food by food, from meat to bread to rice. That's a narrowing that's getting tighter, whereas a fixed narrowing produces the same symptom with the same foods for years.

1:36Put together, progressive solid-food dysphagia in someone with decades of untreated reflux is a peptic stricture until proven otherwise. A peptic stricture is a scarring narrowing of the distal esophagus that follows years of erosive esophagitis that never healed. The inflammation heals by fibrosis, and fibrosis contracts. Strictures develop in five to twenty-five percent of patients with untreated severe reflux esophagitis, and they've become increasingly uncommon since proton pump inhibitors, PPIs, came into wide use. She's exactly the patient who still gets one: years of reflux, never treated. Patients often present as she did, with a food impaction on top of the progressive dysphagia.

2:19Her improving heartburn fits the diagnosis rather than arguing against it, though a patient will offer it as good news. As the stricture narrows the lumen, it reduces the volume of refluxed contents that can get back up through it. So heartburn often eases in the months when dysphagia sets in. Her better heartburn doesn't mean her reflux has gone away. It means the scar is now acting as a crude barrier.

2:43What she doesn't have matters too. She hasn't lost weight. Progressive dysphagia at her age always raises the question of cancer, and weight loss would make it more likely. Its absence helps, but it doesn't exclude a tumor. Only the endoscopy and the biopsies do that.

2:59Confirming the stricture is the endoscopy's job, and it has to do more than look. A narrowing at the lower esophagus in a woman her age could be a cancer, and a smooth appearance doesn't prove it isn't. So the stricture itself is biopsied, to exclude malignancy. And the esophagus is biopsied for eosinophilic esophagitis, because it also causes strictures and food impaction, and it needs anti-inflammatory treatment aimed at food antigens rather than acid control alone. Dilating without biopsies misses both.

3:29Her endoscopy shows a smooth, tapered stricture at the junction, sitting above a three-centimeter hiatal hernia. Above the stricture is erosive esophagitis, Los Angeles grade C: mucosal breaks that run continuously between the tops of two or more folds but involve less than seventy-five percent of the circumference. The hernia size is measured from the diaphragmatic pinch to the top of the gastric folds and is always reported, because it later decides which antireflux procedure is possible. The biopsies show inflammation only: no cancer, no eosinophilic esophagitis. She has a peptic stricture. A peptic stricture, like grade C esophagitis, is objective evidence of reflux disease, so she won't need reflux monitoring to prove the diagnosis.

4:13How the stricture is opened follows from what it's made of. A peptic stricture is fibrotic, and scar doesn't stretch easily; forced, it tears. So it's opened with endoscopic dilation, done either with a balloon passed through the scope or with wire-guided bougies, which are rigid, tapered dilators passed over a guidewire. The tool matters less than the principle, and either is fine for her.

4:36The principle is the rule of threes. Once the endoscopist feels moderate resistance, he or she goes up no more than three dilator sizes in that session. The reason is the risk of perforation. Each size stretches the scar a little further, and pushing several sizes past the point of resistance at once can split it through the wall. So a tight stricture is opened gradually, over several sessions, until she can eat solid food.

5:02Keeping it open is the part most often neglected. Dilation treats the scar, not the disease that made it. If her reflux keeps injuring the lining, the scar keeps forming, and the stricture comes back. So the second half of her treatment is acid suppression: a high-dose PPI, taken twice daily, thirty to sixty minutes before breakfast and before dinner. It heals the esophagitis that caused the stricture, and it reduces how often she'll need another dilation. Even on aggressive PPI therapy, about thirty percent of patients need a repeat dilation over the long term. She's told that up front, along with what to watch for: food starting to stick again means she should come back, not wait for an impaction.

5:42She's also taught how to take the PPI, because she's never taken one before. A PPI is a prodrug that binds only acid pumps that are active, and a meal is what switches them on. So it's taken thirty to sixty minutes before a meal, and it takes three to five days to reach its full effect; taken at bedtime or with food, it barely works. A patient whose stricture keeps coming back despite a high-dose PPI should be asked about timing before anything else, because wrong timing is the first thing to check in any PPI failure.

6:11She stays on that PPI indefinitely. A peptic stricture is one of the conditions in which a PPI should never be stopped, along with severe erosive esophagitis and Barrett esophagus. If she later reads about long-term PPI risks and wants to stop, the evidence is reassuring. Most of those concerns come from observational studies, and in a large randomized trial of pantoprazole against placebo over three years, the only outcome that increased was enteric infection. A PPI is still used at the lowest dose that controls the disease, but for her, the lowest effective dose is the high one, and stopping means the stricture comes back.

6:48Her esophagitis grade sets one more follow-up step. Because the inflammation above her stricture was grade C, she needs a repeat endoscopy after the PPI has healed it. Severe inflammation can hide Barrett esophagus underneath, grades C and D carry an increased risk of finding it after healing, and after twenty years of untreated reflux, she's at real risk. If Barrett is found, it's measured, biopsied in four quadrants, and enters surveillance.

7:16Her dilations go well over three sessions, she's eating normally, and her repeat endoscopy after twelve weeks of twice-daily PPI shows healed mucosa without Barrett.

7:25The second patient has food sticking too, and the boards ask for the two to be told apart, because they're treated in opposite ways. A thirty-six-year-old man says that every few months, food sticks suddenly at the bottom of his chest. The last time was a steak at a restaurant; it stuck for twenty minutes, then went down after he drank some water. Between episodes he swallows perfectly normally, for weeks or months at a time. He has occasional heartburn.

7:52His history differs from hers in every way that matters. His dysphagia isn't progressive. It's intermittent, with long stretches of normal swallowing, and it's set off by a large bite of meat. That's the classic steakhouse impaction of a Schatzki ring. A Schatzki ring is a thin, diaphragm-like, circumferential fold of mucosa at the squamocolumnar junction, with squamous lining on its upper surface and columnar lining underneath. It doesn't tighten over time. It has a fixed diameter, and only a bolus large enough to exceed it gets stuck. That's why he swallows normally for months, then has an impaction with a big piece of steak. And it's why the impaction often clears on its own or after a drink washes the bolus down: the ring isn't getting tighter, so a little extra push gets the food past it.

8:35So the two histories separate on one feature: whether the dysphagia is getting worse. Hers progressed over six months, because scar keeps contracting. His has been the same for years, because a thin ring doesn't change.

8:48His endoscopy shows a thin ring at the junction. His esophagus is still biopsied for eosinophilic esophagitis, because it also causes rings and food impaction, especially in young men, and it's the diagnosis that most needs excluding in him. His biopsies are normal.

9:04His treatment is the opposite of hers, and the reason is the structure. Her stricture is thick scar, so it's stretched gradually. His ring is thin, so the goal is to fracture it, not to stretch it. A single pass with one large bougie or balloon, forty-five to sixty French, breaks the ring in one session. Small, gradual dilations would leave it intact.

9:26He also gets a PPI after dilation, even though his heartburn is only occasional. Whether reflux causes Schatzki rings is disputed. But PPI therapy after dilation has been shown to reduce recurrence, even in patients without obvious reflux symptoms.

9:42Here are the traps the boards set in these patients.

9:45In the stricture, taking improving heartburn as reassurance in a patient with progressive dysphagia misreads the scar's effect on reflux. Dilating without biopsies misses both cancer and eosinophilic esophagitis. Overdilating a fibrotic stricture in one session, instead of following the rule of threes, risks perforation.

10:05After dilation, failing to start a twice-daily high-dose PPI, or stopping it later, lets the stricture re-form. Escalating care for a recurrent stricture without first asking when the PPI is taken skips the first check in any PPI failure. And forgetting the repeat endoscopy after grade C or D esophagitis heals misses the Barrett it was hiding.

10:27In the ring, calling intermittent steakhouse impactions a stricture misreads a fixed ring as a progressive one. And treating a Schatzki ring with small, gradual dilations instead of fracturing it with one large dilator leaves it in place.

10:43So, start to finish.

10:45In a reflux patient, steadily progressive solid-food dysphagia is a peptic stricture until proven otherwise, often as heartburn improves. Biopsy it to exclude cancer and eosinophilic esophagitis. Dilate it gradually, with balloons or bougies, by the rule of threes.

11:04Start a twice-daily high-dose PPI taken before meals and continue it for life. Expect about thirty percent to need a repeat dilation, and repeat the endoscopy after healing when the esophagitis was grade C or D.

11:19Intermittent sudden impaction with normal swallowing between episodes is a Schatzki ring. Biopsy for eosinophilic esophagitis, fracture the ring with one large dilator, and give a PPI afterward to reduce recurrence.

11:32The next chapter follows reflux to its most important long-term complication: Barrett esophagus, who to screen, how surveillance and dysplasia are managed, and esophageal cancer.

11:43For the full chapter, the practice vignettes, and the topic-tagged question bank, head to board pearls dot com. You'll find the rest of the series on Apple Podcasts, Spotify, or wherever you listen to podcasts. That brings us to the end of episode three of three of chapter three, and I'll see you in the next one.