Guideline Recommendations for Managing Tertiary Esophageal Contractions

Diagnostic Approach

• Perform upper‑GI endoscopy, high‑resolution manometry, 24‑hour pH monitoring, and barium swallow to delineate the mechanism of dysphagia before any invasive therapy is considered. 1

First‑Line Pharmacologic Management

• Initiate high‑dose proton‑pump inhibitor (PPI) therapy as the primary treatment; PPIs provide superior symptom relief and reduce the need for repeat interventions compared with H₂‑receptor antagonists. 2

Endoscopic Interventions

• Conduct pneumatic esophageal dilation on a weekly or bi‑weekly schedule until an easy passage of a ≥ 15 mm dilator is achieved, which is associated with symptomatic improvement. 3

Monitoring and Follow‑Up After Endoscopic Procedures

• Observe patients for a minimum of 2 hours post‑procedure, give clear written instructions on fluids, diet, and medications, and maintain a high index of suspicion for perforation (persistent pain, dyspnea, fever, tachycardia); obtain a CT scan with oral contrast if perforation is suspected. 3

Considerations for Refractory Dysphagia

• When dysphagia persists despite an apparently adequate esophageal lumen, evaluate for alternative neuromuscular etiologies. 4
• Ensure optimal control of esophageal inflammation with high‑dose PPI therapy before labeling dysphagia as refractory. 4