Dilatation

Common Uses of Dilatation

1. Esophageal Strictures:

   • Benign Esophageal Strictures: Narrowing of the esophagus caused by acid reflux, scarring from surgery, ingestion of caustic substances, or certain diseases like eosinophilic esophagitis.
   • Malignant Esophageal Strictures: Caused by esophageal cancer or tumors pressing on the esophagus.
   • Achalasia: A disorder where the muscles of the esophagus and the lower esophageal sphincter (LES) fail to relax properly, causing difficulty swallowing.

2. Pyloric Stenosis:

   • Narrowing of the opening between the stomach and the small intestine (pylorus), often due to scarring from ulcers, tumors, or other diseases.

3. Colonic and Intestinal Strictures:

   • Narrowing of parts of the colon or small intestine, which may be caused by Crohn’s disease, surgical scarring, or cancer.

4. Biliary and Pancreatic Duct Strictures:

   • Narrowing of the bile ducts or pancreatic ducts due to gallstones, tumors, or inflammation.

5. Urethral Strictures:

   • Narrowing of the urethra, which may be caused by infections, trauma, or surgery.

6. Airway Strictures:

   • Narrowing of the trachea or bronchus, which can occur after intubation, trauma, or due to tumors or inflammatory diseases.

Techniques of Dilatation

The exact method of dilatation depends on the location and cause of the stricture. The following techniques are commonly used:

1. Endoscopic Balloon Dilatation:

   • A balloon catheter is passed through an endoscope (a flexible tube with a camera), and once in place at the stricture site, the balloon is inflated to stretch or widen the narrowed area. The procedure is visualized in real time on a monitor, ensuring the correct placement and extent of dilation.

2. Bougie Dilatation:

   • This method uses a tapered, flexible rod called a bougie that is gently passed through the stricture to gradually widen it. Different sizes of bougies are used, starting with the smallest and progressively increasing to larger diameters.

3. Fluoroscopic Dilatation:

   • Performed under fluoroscopic (X-ray) guidance, this technique is used when real-time imaging is necessary, especially for areas that are not easily accessible by an endoscope, such as bile ducts or other internal passages.

4. Savary-Gilliard Dilators:

   • Similar to bougie dilators, these are wire-guided dilators often used to treat esophageal strictures. A guidewire is first passed through the stricture, and the dilators of increasing size are then passed over the wire.

Indications for Dilatation

• Difficulty Swallowing (Dysphagia): Most commonly due to esophageal strictures.
• Obstruction Symptoms: Such as abdominal pain, vomiting, or constipation, when there is a blockage in the stomach, intestines, or bile ducts.
• Difficulty Urinating: Caused by urethral strictures.
• Airway Obstruction: In cases of tracheal or bronchial strictures, causing breathing difficulties.

Procedure

1. Preparation:
   • The patient is usually sedated, especially during endoscopic or balloon dilatation procedures.
   • Local anesthesia may also be used in the case of certain strictures (e.g., the urethra).
2. Dilatation Process:
   • An endoscope is inserted into the appropriate organ (esophagus, bile duct, intestine) to visualize the stricture.
   • Once the stricture is located, the selected dilator (balloon, bougie, or wire-guided device) is introduced.
   • Gradual widening occurs either through inflation of the balloon or the progressive insertion of larger bougies.
3. Monitoring:
   • The patient is closely monitored for any signs of perforation, bleeding, or other complications during and after the procedure.
4. Post-procedure:
   • The patient may experience mild discomfort or soreness, depending on the location of the dilatation, but serious side effects are uncommon.

Benefits of Dilatation

• Minimally Invasive: It offers an alternative to more invasive surgical interventions, such as stricturoplasty or resection.
• Immediate Symptom Relief: Patients often experience immediate improvement in symptoms like difficulty swallowing or obstruction.
• Repeatable: Dilatation can be repeated if strictures recur, which is common in certain conditions like achalasia or Crohn’s disease.

Risks and Complications

• Perforation: The most significant risk is tearing or perforation of the organ being dilated, especially with aggressive or repeated dilatation.
• Bleeding: There may be minor bleeding from the site of dilatation, although major bleeding is rare.
• Infection: Especially in cases of biliary or pancreatic duct dilatation.
• Recurrent Strictures: Strictures often recur, particularly if caused by chronic conditions like reflux or Crohn’s disease, and repeat dilatation may be necessary.

Alternatives to Dilatation

• Surgical Stricture Resection: In cases where dilatation is not effective or appropriate, surgery to remove the narrowed segment may be required.
• Stenting: Insertion of a stent (a tube to keep the area open) may be considered, especially for strictures caused by cancer or those that do not respond to dilatation.
• Medication: For strictures caused by inflammation, medications (e.g., steroids, acid suppressants) may be used to manage the underlying cause and prevent recurrence.