Balloon dilation of double strictures after corrosive esophagitis
Journal
Journal of Pediatric Gastroenterology and Nutrition
Journal Volume
32
Journal Issue
4
Pages
496-498
Date Issued
2001
Author(s)
Abstract
The patient in this case report is a 2-year-4-month-old boy who mistakenly ingested a strong alkaline fluid, which resulted in corrosive esophagitis. The patient developed dysphagia after 2 weeks. An esophagogram showed double strictures at the upper portion of esophagus. Fluoroscopy-guided balloon dilations on these two strictures have been performed successfully. Follow-up esophagogram revealed fluent passage of contrast medium. The patient can swallow solid food and has good body weight gain after balloon dilation. This fluoroscopy-guided balloon dilation is an alternative and safe procedure for separated strictures in esophagus compared with the endoscopy-guided dilator, which is difficult to use in this case. CASE REPORT The patient, a 2-year-4-month-old boy, ingested a strong alkaline solution (96% NaHCO3 and 4% KHCO3, pH > 9) accidentally. The next day, panendoscopy (Olympus N-30, Japan) was performed while the patient was under intravenous anesthesia (midazolam 0.2 mg/kg) without endotracheal intubation. The panendoscopy revealed diffuse erosions with whitish plaque and hemorrhagic spots along the esophagus. No circumferential ulcer was noted. We determined that the patient had a grade IIa esophageal injury. The stomach had petechiae at fundus and high body. The patient was given conservative treatment with intravenous fluids and antibiotics. Initially, the child could swallow solid and liquid well. However, he developed dysphagia 2 weeks later. An esophagogram revealed two separated strictures at the upper esophagus (Fig. 1A). Attempted endoscopy-guided (Olympus N-30, Japan) dilation failed because of inability to pass the dilator through the malaligned stricture sites. Therefore, balloon catheter dilation with fluoroscopic guidance was performed 3 days later. After smooth passage of a stiff guidewire through these strictures, a balloon catheter (12 mm diameter; 40 mm length; Accent, Cook, IN, U.S.A.) was inserted. Inflation was performed 4 times (3 atm) and each inflation lasted 3 minutes. These two strictures were dilated simultaneously because a long balloon could sufficiently cover the short distance. An immediate post-dilated esophagogram showed good passage of water-soluble contrast medium. One month later, dysphagia recurred. A follow-up esophagogram showed restenosis at the original sites, but stenosis was not as severe as the first occurrence. Therefore, the second balloon catheter dilation (15 mm diameter, 40 mm length, 6 atm) was performed.FIG. 1.: A: Barium esophagogram shows oblique view of double strictures (arrows) in the upper esophagus at about the level of the thoracic inlet. Proximal stricture was so tortuous that an endoscope could not be introduced. B: Fluoroscopy-guided full balloon dilation was performed with a 12-mm balloon catheter to relieve both strictures. C: Esophagogram obtained after final balloon dilation shows a patent esophageal lumen.Figure 1: ContinuedFigure 1: ContinuedAfter the second dilation, the patient could swallow without difficulty. However, an esophagogram revealed moderate restenosis of the upper esophagus, so the third balloon catheter dilation (12 mm diameter, 40 mm length, 6 atm) was performed (Fig. 1B). All the dilation procedures were performed while the patient was under intravenous anesthesia with midazolam (0.2 mg/kg). Endotracheal intubation was not performed during the procedures. A post-dilation esophagogram showed total relief of the original stenotic sites with very fluent passage of contrast medium (Fig. 1C). At 7-month follow-up, the patient had no difficulty eating. DISCUSSION Accidental ingestion of a caustic substance is a common problem in children (1). Caustic burns of the esophagus can lead to serious complications. Approximately 7% to 15% of children develop esophageal strictures after corrosive esophagitis (2,3). Since London et al. (4) reported successful balloon catheter dilation treatment for esophageal strictures in 1981, it has become a preferred treatment for severe and tight gastrointestinal strictures. Compared with bougie dilation, balloon dilation is less traumatic, safer, and more effective because it works by yielding uniform radial forces rather than shearing axial forces on the stricture segment (5). Our present case report describes a patient who, after ingesting a strong alkaline solution, developed corrosive esophagitis that developed into double esophageal strictures. Initially, endoscopy-guided balloon dilation was believed to be the treatment of the choice. However, we could not pass the endoscope beyond the proximal stricture. This method was not the appropriate treatment for this patient because he had two strictures that were close to each other and that were malaligned. Therefore, fluoroscopy-guided balloon dilation was performed. Neither conventional bougie or endoscopy-guided dilation is suitable for this situation, because there are two severe strictures and the tortuosity of the esophagus near the stricture sites may prevent manipulation of a bougie dilator or an endoscope through the stricture. Fluoroscopic guidance provided complete visualization of the lesions and an overall outline of the double strictures. This is better than the endoscope because the endoscope simply reveals the inner mucosa of the esophagus. The balloon can therefore be positioned and inflated correctly and effectively. It allows for resolution of the two strictures at the same time. However, use of balloon dilation instead of bougie is advocated to prevent shear forces and the chance of perforation for patients with severe esophageal strictures. Therefore, we advocate that the indications of fluoroscopy-guided balloon dilation for esophageal strictures are as follows: (1) severe stricture lesion beyond which the endoscope or bougie can not pass; (2) multiple esophageal strictures with tortuosity before or between stricture sites; (3) deep esophageal ulceration (above grade IIb) with a high risk of perforation during the manipulation of dilation. The endoscopy-guided balloon dilation for esophageal stricture is indicated for the single esophageal stricture with mild to moderate stenosis. This patient received balloon dilation treatment three times within 8 months after alkali ingestion. Because scar tissue will contract up to 6 months after the start of the healing process, periodic dilation has to be performed for a long time with a range from 6 weeks to 12 years . The patient has had no feeding difficulty for 7 months after the third dilation. It seems that the stricture-free duration can be prolonged gradually after dilation. This case report describes a patient with double esophageal strictures after corrosive injury. It is the first report, to our knowledge, of simultaneous dilation of two strictures using by fluoroscopic balloon dilation successfully. However, a long-term follow-up is warranted for prevention or further intervention of any recurrent stenosis.
Type
journal article