Esophageal stricture overview: Difference between revisions
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{{CMG}}; {{AE}}{{MA}} [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] | {{CMG}}; {{AE}}{{MA}} [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] | ||
{{Esophageal stricture}} | {{Esophageal stricture}} | ||
==Overview== | ==Overview== | ||
It is thought that esophageal stricture is the result of lower pressure of [[esophageal sphincter]] in [[gastroesophageal reflux disease]], esophageal motor disorder, [[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 [[Esophagogram|esophagography]], [[esophagogastroduodenoscopy]], [[endoscopic ultrasound]], [[manometry]]. [[Pharmacologic]] medical therapy for esophageal stricture secondary to [[gastroesophageal reflux disease]] includes [[Proton pump inhibitor|proton pump inhibitors]] or [[Histamine-2 receptor blocker|H2 antagonists]]. The mainstay of treatment for esophageal stricture is [[dilation]]. Self-expandable plastic or [[Stent|metal stents]] placement is indicated for patients with | It is thought that esophageal stricture is the result of lower pressure of [[esophageal sphincter]] in [[gastroesophageal reflux disease]], esophageal motor disorder, [[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 [[Esophagogram|esophagography]], [[esophagogastroduodenoscopy]], [[endoscopic ultrasound]], [[manometry]]. [[Pharmacologic]] medical therapy for esophageal stricture secondary to [[gastroesophageal reflux disease]] includes [[Proton pump inhibitor|proton pump inhibitors]] or [[Histamine-2 receptor blocker|H2 antagonists]]. The mainstay of treatment for esophageal stricture is [[dilation]]. Self-expandable plastic or [[Stent|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== | ==Historical Perspective== | ||
First intervention for esophageal stricture was done in the 17 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 | First intervention for esophageal stricture was done in the 17 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 cancer|esophageal carcinoma]] was performed by Vincenz Czerny. The first stent was introduced in 1990. | ||
==Classification== | ==Classification== | ||
There is no established system for the 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== | ==Pathophysiology== | ||
It is thought | It is thought that 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]], pale [[mucosa]] in [[lymphocytic]] [[esophagitis]] and [[hemorrhagic]] [[congestion]] in [[caustic]] ingestion. | ||
[[Microscopic]] [[histopathological]] characteristic findings | [[Microscopic]] [[histopathological]] characteristic findings of esophageal stricture is inntraepithelial [[lymphocytes]] and [[basal cell]] [[hyperplasia]] in [[gastroesophageal reflux disease]], [[Infiltration (medical)|infiltration]] [[T lymphocytes]] in [[squamous]] [[mucosa]] in [[lymphocytic]] [[esophagitis]] and [[eosinophilic]] [[necrosis]] in [[caustic]] ingestion | ||
==Causes== | ==Causes== | ||
Common causes | Common causes of esophageal stricture include [[gastroesophageal reflux disease]] and [[caustic]] ingestions. | ||
==Differentiating esophageal stricture from Other Diseases== | ==Differentiating esophageal stricture from Other Diseases== | ||
Esophageal stricture must be differentiated from plummer-vinson syndrome, [[achalasia]] , | Esophageal stricture must be differentiated from plummer-vinson syndrome, [[achalasia]] , [[diffuse esophageal spasm]], [[systemic sclerosis]], [[zenker's diverticulum]], [[Esophageal cancer|esophageal carcinoma]], [[stroke]], motor disorders, [[GERD]][[Esophageal web|, esophageal web]]. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Most | Most of esophageal strictures are related to [[gastroesophageal reflux disease]]. 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 yr but there is similar [[incidence]] in men and women after age 60. | ||
==Risk Factors== | ==Risk Factors== | ||
The most potent [[risk factor]] in the development | The most potent [[risk factor]] in the development of esophageal stricture is frequent [[acid reflux]]. Other [[risk factor]]<nowiki/>s include [[Hiatus hernia|hiatal hernia]], [[obesity]], [[smoking]], [[esophageal dysmotility]], increased [[gastric]] acidity, and heavy [[alcohol]] use. | ||
==Screening== | ==Screening== | ||
There is insufficient evidence to recommend routine [[screening]] | There is insufficient evidence to recommend routine [[screening]] for esophageal stricture. | ||
==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
If left untreated, patients | If left untreated, patients with esophageal stricture may progress to develop [[pulmonary aspiration]], [[weight loss]], and [[dehydration]]. Common [[complication]]<nowiki/>s of esophageal stricture include [[perforation]], [[bleeding]], [[pneumonia]], [[bacteremia]]. [[Prognosis]] is generally good but recurrence of symptoms after [[dilation]] are prevalent and usually recurrent [[dilation]] is necessary. | ||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic study of choice=== | ===Diagnostic study of choice=== | ||
Esophageal stricture is diagnosed based on history of [[dysphagia]] and diagnostic studies such as barium [[Esophagogram|esophagography]], [[esophagogastroduodenoscopy]], [[endoscopic ultrasound]], [[manometry]]. | |||
===History and Symptoms=== | ===History and Symptoms=== | ||
The hallmark | 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 (medical)|chronic]] [[cough]] and [[wheezing]]. | ||
===Physical Examination=== | ===Physical Examination=== | ||
Patients with esophageal stricture can usually appear normal. [[Cachexia]] and [[pallor]] are notable in patients | Patients with esophageal stricture can usually appear normal. [[Cachexia]] and [[pallor]] are notable in patients with esophageal stricture due to [[malignant]] causes. | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
Laboratory findings are usually normal among patients | Laboratory findings are usually normal among patients with esophageal stricture although [[anemia]] may be seen with [[malignant]] causes of esophageal stricture. Other possible laboratory test are high serum [[gastrin]] level in [[Zollinger-Ellison syndrome|zollinger ellison syndrome]] and peripheral [[eosinophilia]] in [[eosinophilic esophagitis]] as causes of esophageal stricture. | ||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
There are no ECG findings associated with esophageal stricture. | There are no [[The electrocardiogram|ECG]] findings associated with esophageal stricture. | ||
===X-ray=== | ===X-ray=== | ||
A [[Chest X-ray|chest x-ray]] may be helpful in the diagnosis of [[tumors]] as a cause | A [[Chest X-ray|chest x-ray]] may be helpful in the diagnosis of [[tumors]] as a cause of esophageal stricture. | ||
===CT scan=== | ===CT scan=== | ||
[[Chest]] [[CT scan]] may be helpful in the diagnosis of [[malignant]] causes | [[Chest]] [[CT scan]] may be helpful in the diagnosis of [[malignant]] causes of esophageal stricture. | ||
===MRI=== | ===MRI=== | ||
In general [[MRI]] has not been routinely recommended for | In general [[MRI]] has not been routinely recommended for esophageal stricture. | ||
===Echocardiography or Ultrasound=== | ===Echocardiography or Ultrasound=== | ||
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===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
Barium [[Esophagogram|esophagography]] is helpful in the diagnosis | Barium [[Esophagogram|esophagography]] is helpful in the diagnosis of esophageal stricture. Findings on a barium [[esophagogram]] suggestive of [[benign]] esophageal stricture include [[concentric]] narrowing, smoothly tapering and eccentric narrowing, abrupt, asymmetric in [[malignant]] causes. | ||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
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==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
[[Pharmacologic]] medical therapy | [[Pharmacologic]] medical therapy for esophageal stricture secondary to [[gastroesophageal reflux disease]] includes [[Proton pump inhibitor|proton pump inhibitors]] or [[Histamine-2 receptor blocker|H2 antagonists]]. Patients are advised to consider life style modification for [[gastroesophageal reflux disease]]. | ||
===Surgery=== | ===Surgery=== | ||
==== Procedure ==== | ==== Procedure ==== | ||
The mainstay of treatment | The mainstay of treatment for esophageal stricture is [[dilation]]. Self-expandable plastic or [[Stent|metal stents]] placement is indicated for patients with refractory esophageal stricture. | ||
==== surgical management ==== | ==== surgical management ==== | ||
[[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 | [[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 === | === Primary Prevention === | ||
Effective measures for the [[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=== | ===Secondary Prevention=== | ||
Effective measures for the secondary prevention | Effective measures for the secondary prevention of esophageal stricture include lifestyle modification, [[Proton pump inhibitor|proton pump inhibitors]] or [[Histamine-2 receptor blocker|H2 antagonists]].<gallery> | ||
Image: | Image: | ||
Revision as of 19:28, 22 November 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2] [3] [4] [5]
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Overview
It is thought that esophageal stricture is the result of lower pressure of esophageal sphincter in gastroesophageal reflux disease, esophageal motor disorder, 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, 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
First intervention for esophageal stricture was done in the 17 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
It is thought that 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, pale mucosa in lymphocytic esophagitis and hemorrhagic congestion in caustic ingestion.
Microscopic histopathological characteristic findings of esophageal stricture is inntraepithelial lymphocytes and basal cell hyperplasia in gastroesophageal reflux disease, infiltration T lymphocytes 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, GERD, esophageal web.
Epidemiology and Demographics
Most of esophageal strictures are related to gastroesophageal reflux disease. 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 yr 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, 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, 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 malignant causes.
Laboratory Findings
Laboratory findings are usually normal among patients with esophageal stricture although anemia may be seen with malignant causes of esophageal stricture. Other possible laboratory test 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, smoothly tapering and eccentric narrowing, abrupt, asymmetric in malignant causes.
Other Diagnostic Studies
Other diagnostic study 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
Procedure
The mainstay of treatment for esophageal stricture is dilation. Self-expandable plastic or metal stents placement is indicated for patients with refractory esophageal stricture.
surgical management
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.
