esophageal stricture

Etiology

• gastric acid (peptic) esophagitis
  • gastroesophageal reflux (GERD) (70%)
  • Zollinger-Ellison
• connective tissue disorders
  • scleroderma
  • systemic lupus erythematosus (SLE), rheumatoid arthritis
• graft versus host disease
• Crohn's disease
• infectious disease:
  • esophageal candidiasis
  • herpes simplex virus
  • cytomegalovirus (CMV)
  • HIV1
• diseases of the skin
  • pemphigus vulgaris
  • cicatricial pemphigoid
  • epidermolysis bullosa dystrophica
• ingestions of caustic agents (acid or alkali)
• congenital disorders
• iatrogenic disorders
  • sclerotherapy
  • prolonged nasogastric intubation
• medication-induced:
  • alendronate, ferrous sulfate, NSAIDs, phenytoin, KCl, quinidine, tetracycline, ascorbic acid
• radiation exposure
• malignancies
• idiopathic eosinophilic esophagitis
• idiopathic

Epidemiology

• 10-fold more common in whites than blacks or Asians
• 2-3-fold more common in men than in women
• patients tend to be older, with longer duration GERD

Pathology

• intrinsic esophageal pathology can narrow the esophageal lumen via inflammation, fibrosis, or neoplasia
• extrinsic pathology can compress the esophageal lumen by direct invasion or lymph node enlargement
• disorders of esophageal peristalsis &/or the lower esophageal sphincter can narrow the esophageal lumen via effects on esophageal smooth muscle & its innervation

Clinical manifestations

• progressive dysphagia for solids is the most common presenting symptom; may progress to include liquids
• heartburn, dysphagia, odynophagia, food impaction, weight loss, chest pain may be present
• chronic cough & asthma due to aspiration of food or acid less common

Diagnostic procedures

• EGD with tissue biopsy
• esophageal mannography when dysmotility is suspected

Radiology

• barium swallow may be an appropriate initial test
• computed tomography may be useful for assessing extrinsic pathology
• esophageal ultrasound may be useful for assessing extrinsic pathology

Differential diagnosis

• obstruction is generally perceived at a point either above or at the level of the lesion
• dysphagia for solids & liquids simultaneously suggests a motility disorder, i.e. achalasia, connective tissue disorder
• dysphagia secondary to Schatzki ring is generally intermittent & nonprogressive
• benign esophageal strictures usually produce dysphagia with slow & insidious progression (months to years) & minimal weight loss
• malignant esophageal strictures usually produce a rapid progression (weeks to months) & significant weight loss

Management

• treatment of GERD
• esophageal dilation
• investigational procedures
  • endoscopic stricturoplasty
  • esophageal stent
    • self-expanding metal stent for malignant esphageal stricture
• other surgical procedures

More general terms

• stricture
• esophageal disease