Esophageal stricture overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]
Overview
Esophageal stricture is the result of increased pressure of lower esophageal sphincter. It is associated with disorders such as gastroesophageal reflux disease, esophageal motor disorders, inflammation and fibrosis in neoplasia. Common causes of esophageal stricture include gastroesophageal reflux disease and caustic ingestions. Overall incidence of esophageal stricture is approximately 11 per 100,000 individuals and the prevalence of esophageal stricture is approximately 70-120 per 100,000 individuals in united states.The most potent risk factor in the development of esophageal stricture is frequent acid reflux. Esophageal stricture is diagnosed based on history of dysphagia and diagnostic studies such as barium esophagography, esophagogastroduodenoscopy, endoscopic ultrasound, and manometry. Pharmacologic medical therapy for esophageal stricture secondary to gastroesophageal reflux disease includes proton pump inhibitors or H2 antagonists. The mainstay of treatment for esophageal stricture is dilation. Self-expandable plastic or metal stents placement is indicated for patients with refractory esophageal stricture. Surgery is usually reserved for patients with either inability to dilate the stricture, frequent recurrence of dysphagia, extraesophageal manifestations and long term side effects of medical therapy.
Historical Perspective
The first intervention for esophageal stricture was done in the 17th century by Whalebone. The first bougienage was performed in 1801. In 1868, esophagoscope was developed for the first time. In 1877, first surgical resection for esophageal carcinoma was performed by Vincenz Czerny. The first stent was introduced in 1990.
Classification
There is no established system for the classification of esophageal stricture, but it may be classified into benign and malignant according to causes.
Pathophysiology
Esophageal stricture is the result of lower pressure of esophageal sphincter in gastroesophageal reflux disease, esophageal motor disorder, inflammation and fibrosis in neoplasia. The most characteristic finding in gross pathology is thickening of the lower esophageal wall in gastroesophageal reflux disease, a pale mucosa in lymphocytic esophagitis and hemorrhagic congestion in caustic ingestion. Microscopic histopathological characteristic findings of esophageal stricture is intraepithelial lymphocytosis, basal cell hyperplasia in gastroesophageal reflux disease, T lymphocytes infiltration in squamous mucosa in lymphocytic esophagitis and eosinophilic necrosis in caustic ingestion
Causes
Common causes of esophageal stricture include gastroesophageal reflux disease and caustic ingestions.
Differentiating esophageal stricture from Other Diseases
Esophageal stricture must be differentiated from Plummer-Vinson syndrome, achalasia, diffuse esophageal spasm, systemic sclerosis, zenker's diverticulum, esophageal carcinoma, stroke, motor disorders such as Myasthenia Gravis, GERD, esophageal web.
Epidemiology and Demographics
Most of the esophageal strictures are related to gastroesophageal reflux disease. The overall incidence of esophageal stricture is approximately 11 per 100,000 individuals and the prevalence of esophageal stricture is approximately 70-120 per 100,000 individuals in united states. The incidence of esophageal stricture increases with age. There is no racial predilection to esophageal stricture. The risk of esophageal stricture is higher in men under 60 years but there is similar incidence in men and women after age 60.
Risk Factors
The most potent risk factor in the development of esophageal stricture is frequent acid reflux. Other risk factors include hiatal hernia, obesity, smoking, esophageal dysmotility, increased gastric acidity, and heavy alcohol use.
Screening
There is insufficient evidence to recommend routine screening for esophageal stricture.
Natural History, Complications, and Prognosis
If left untreated, patients with esophageal stricture may progress to develop pulmonary aspiration, weight loss, and dehydration. Common complications of esophageal stricture include perforation, bleeding, pneumonia and bacteremia. Prognosis is generally good but recurrence of symptoms after dilation are prevalent and usually recurrent dilation is necessary.
Diagnosis
Diagnostic study of choice
Esophageal stricture is diagnosed based on history of dysphagia and diagnostic studies such as barium esophagography, esophagogastroduodenoscopy, endoscopic ultrasound and manometry.
History and Symptoms
The hallmark of esophageal stricture is dysphagia . A positive history of heartburn is suggestive of esophageal stricture. The most common symptoms of esophageal stricture include dysphagia, odynophagia, and heartburn. Less common symptoms of esophageal stricture include chronic cough and wheezing.
Physical Examination
Patients with esophageal stricture can usually appear normal. Cachexia and pallor are notable in patients with esophageal stricture due to neoplastic causes.
Laboratory Findings
Laboratory findings are usually normal among patients with esophageal stricture although anemia may be seen with neoplastic causes of esophageal stricture. Other possible laboratory tests are high serum gastrin level in zollinger ellison syndrome and peripheral eosinophilia in eosinophilic esophagitis as causes of esophageal stricture.
Electrocardiogram
There are no ECG findings associated with esophageal stricture.
X-ray
A chest x-ray may be helpful in the diagnosis of tumors as a cause of esophageal stricture.
CT scan
Chest CT scan may be helpful in the diagnosis of malignant causes of esophageal stricture.
MRI
In general MRI has not been routinely recommended for esophageal stricture.
Echocardiography or Ultrasound
There are no echocardiography findings associated with esophageal stricture. Endoscopic ultrasound may be helpful in the diagnosis of malignant causes of esophageal stricture.
Other Imaging Findings
Barium esophagography is helpful in the diagnosis of esophageal stricture. Findings on a barium esophagogram suggestive of benign esophageal stricture include concentric narrowing and smooth tapering. Eccentric narrowing, abrupt and asymmetric narrowing are suggestive of malignant causes.
Other Diagnostic Studies
Other diagnostic studies for esophageal stricture include esophagogastroduodenoscopy (EGD) for detection malignant causes. Manometry is used in cases of esophageal stricture due to dysmotility.
Treatment
Medical Therapy
Pharmacologic medical therapy for esophageal stricture secondary to gastroesophageal reflux disease includes proton pump inhibitors or H2 antagonists. Patients are advised to consider life style modification for gastroesophageal reflux disease.
Surgery
The mainstay of treatment for esophageal stricture is dilation. Self-expandable plastic or metal stents placement is indicated for patients with refractory esophageal stricture.
Surgery is usually reserved for patients with either inability to dilate the stricture, frequent recurrence of dysphagia, extraesophageal manifestations and long term side effects of medical therapy
Primary Prevention
Effective measures for the primary prevention of esophageal stricture include treatment and life style modification for gastroesophageal reflux disease, taking pills with a full glass of water and storing all corrosive chemicals.
Secondary Prevention
Effective measures for the secondary prevention of esophageal stricture include lifestyle modification, proton pump inhibitors or H2 antagonists.