Esophageal stricture differential diagnosis

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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 must be differentiated from plummer-vinson syndrome, achalasia , diffuse esophageal spasm, systemic sclerosis, zenker's diverticulum, esophageal carcinoma, stroke, motor disorders, GERD, esophageal web.

Differentiating Esophageal stricture from other Diseases

• Esophageal stricture must be differentiated from other diseases that cause dysphagia such as plummer-vinson syndrome, achalasia , diffuse esophageal spasm, systemic sclerosis, zenker's diverticulum, esophageal carcinoma, stroke(cerebral hemorrhage), motor disorders(myasthenia gravis), GERD, esophageal web.

Dysphagia                                                                                                                                                                                 Oropharyngeal dysphagia                                                   Esophageal dysphagia                                                                                                                                                                                             Solids only                         Solids and Liquids                     Solids only                   Solids and Liquids                                                                                                                                                 •Zenker's diverticulum •Neoplasm •Webs                   Neurogenic       Myogenic               Pain                   •Achalasia •Scleroderma •DES                                                                                                                                                                                               •Myasthenia gravis •Connective tissue disorder •Myotonic dystrophy         No         Yes           Heart burn               Barium swallow                   Mental status                                                                                                                                                                                   •Pill esophagitis •Caustic injury •Chemotherapy     Yes       No                                                                       Impaired       Normal         Non progressive       Progressive                                                                 Sac     Webs     Mass                                                                   Scleroderma       •Achalasia •DES                                     Stroke       •ALS •Parkinsonism         •Rings •Webs       •Strictures •Cancer                                   Zenker's diverticulum     Plummer-Vinson syndrome     Carcinoma                                                                           Chest pain and manometry                                                         Barium swallow       Weight loss                                                                                                                                           Increase LES pressure                                                                     Rings       Webs                                                                                                                                                                     Yes       No                                                                                   Rapid       Slow                                                                                                                                   Achalasia       DES                                                                 Cancer       Strictures/GERD

Preferred Table

Disease	Signs and Symptoms								Barium esophagogram	Endoscopy	Other imaging and laboratory findings	Gold Standard
	Onset	Dysphagia			Weight loss	Heartburn	Other findings	Mental status
		Solids	Liquids	Type
Plummer-Vinson syndrome	Gradual	+	-	Non progressive	+/-	-	Glossitis Koilonychia	Normal	Thin projections on the anterior esophageal wall Multiple upperesophageal constrictions	Direct visualization of esophageal webs Superior to esophagogram	Videofluoroscopy shows mucosal and submucosal foldings	Triad of Iron deficiency anemia Esophageal webs Glossitis
Esophageal stricture	Gradual or sudden	+	-	Progressive	+/-	+/-	Odynophagia Cough Chest pain	Normal	Sacculations Fixed transverse folds Esophageal intramural pseudodiverticula	Mucosal edema Circumferential thickening in GERD Pale mucosa with white exudate in lymphocytic esophagitis Swelling and hemorrhagic congestion in causticingestion	Manometry may show dysmotility CT scan for staging malignant strictures	No gold standard test Diagnostic study based on history of dysphagia, positive barium esophagogramand endoscopy
Diffuse esophageal spasm	Sudden	+	+	Non progressive	+	+	Chest pain	Normal	Nonperistaltic and nonpropulsive contractions Corkscrew or rosary bead esophagus	Inconclusive	Manometry shows high-amplitude esophageal contractions CT scan may show hypertrophy of esophageal muscles	Manometry
Achalasia	Gradual	+	+	Non progressive	+/-	-	Regurgitation of undigested food Chest pain	Normal	"Bird's beak" or "rat tail" appearance Dilated esophageal body Air fluid level (absent peristalsis) Absence of an intragastric air bubble	Dilated esophagus Residual food fragments Normal mucosa	Residual pressure of LES > 10 mmHg Incomplete relaxation of the LES Increased resting tone of LES Aperistalsis	History of dysphagia with positive endoscopy and manometry
Systemic sclerosis	Gradual	+	+	Progressive	+/-	+	Muscle and joint pain Raynaud's phenomenon Skin changes	Normal	Dysmotility Patulous esophagus	Mucosal damage Peptic stricture (advanced cases)	Positive serology for Antinuclear antibodies Rheumatoid factor Creatine kinase ESR	Skin biopsy
Zenker's diverticulum	Gradual	+	-		+/-	-	Food regurgitation Halitosis Cough Hoarseness	Normal	Thin projections on esophageal wall over Killian's triangle	Outpouching of posterior pharyngeal wall Exclude the presence of SCC	CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle	Barium esophagography
Esophageal carcinoma	Gradual	+	+	Progressive	+	+/-	Lymphadenopathy Cachexia	Normal	Irregular stricture Pre-stricture dilatation	Esophageal obstruction Staging of disease	CT and PET scan is an optional test for staging of the disease	Biopsy
Stroke (Cerebral hemorrhage)	Sudden	+	+	Progressive	+	+/-	Dysarthria Limb weakness Fatigue	Impaired	Pooling of contrast in the pharynx Aspiration of barium contrast into the airway	Reduced opening of upper esophageal sphincter Reduced larynx elevation	CT without contrast shows acute hemorrhage as a hyperattenuating clot	CT without contrast
Motor disorders (Myasthenia gravis)	Gradual	+	+	Progressive	+/-		Ptosis Diplopia Fatigue	Normal	Stasis in pharynx and pooling in pharyngeal recesses	Velopharyngeal insufficiency Delayed swallowing function	CT may show anterior mediastinal mass (thymoma) Positive tensilon test	Anti–acetylcholine receptor antibody test
GERD	Gradual or sudden onset	+	-	Progressive	+/-	+	Cough Hoarseness	Normal	Free acid reflux Esophagitis with scarring Strictures Barrett's oesophagus	Erythema, erosions and ulceration Barrett's esophagus	Esophageal manometry may show decreased tone of LES	24 hour esophageal pH monitoring
Esophageal web	Gradual	+	+/-	Progressive	-	+/-	Findings of the underlying cause such as iron deficiency anemia or bullous pemphigoid	Normal	Symmetrical narrowing of the esophagus	Smooth membrane not encircling the whole lumen	Videofluoroscopy shows mucosal and submucosal foldings	Barium esophagogram

| +/- |Progressive | - | +/- |

• Findings of the underlying cause such as iron deficiency anemia or bullous pemphigoid

|Normal |

• Symmetrical narrowing of the esophagus

|

• Smooth membrane not encircling the whole lumen

|

• Videofluoroscopy shows mucosal and submucosal foldings

|

• Barium esophagogram

|}

	Manifestations	Diagnostic tools
Achalasia	Dyspnea Dysphagia for solids and liquids is the most common feature, being seen in 91 % and 85% of patients respectively Regurgitation of undigested food occurs in 76-91% of patients Cough mainly when lying down in 30%	Esophagogastroduodenoscopy findings include a dilated esophagus with residual food fragments, normal mucosa and occasionally candidiasis (due to the prolonged stasis). Barium swallow shows the characteristic bird's beak appearance. Barium swallow showing bird's beak appearance - By Farnoosh Farrokhi, Michael F. Vaezi. - Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases 2007, 2:38(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2040141), CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=2950922
GERD	Retrosternal burning chest pain. Cough and hoarseness of voice. May present with complications such as strictures and dysphagia.	Upper GI endoscopy shows the complications such as esophagitis and barret esophagus. Esophageal manometry may show decreased tone of the lower esophageal sphincter. 24-hour esophageal pH monitoring may be done to confirm the diagnosis. Barret's esophagus - By Samir धर्म - taken from patient with permission to place in public domain, Copyrighted free use, https://commons.wikimedia.org/w/index.php?curid=1595945
Esophageal carcinoma	Dysphagia Odynophagia- fluids and soft foods are usually tolerated, while hard or bulky substances (such as bread or meat) cause much more difficulty Weight loss Pain, often of a burning nature, may be severe and worsened by swallowing, and can be spasmodic in character Nausea and vomiting	Upper GI endoscopy and esophageal biopsy the gold standard for the diagnosis of esophageal CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=2587715
Corckscrew esophagus	Retrosternal chest pain that presents with or without food intake. The condition is not progressive and not causing complications.	Barium swallow shows the characteristic corckscrew appearance of the esophagus. Corckscrew esophagus - Case courtesy of Radswiki, Radiopaedia.org, rID: 11680
Esophageal stricture	Patient may present with the symptoms of the underlying GERD. Dysphagia and odynophagia.	Barium esophagography provides information about the site and the diameter of the stricture before the endoscopic intervention. Peptic stricture - By Samir धर्म - From en.wikipedia.org, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1931423
Plummer-Vinson syndrome	Common symptoms of Plummer-Vinson syndrome include: Difficulty swallowing (more for solids) Weakness Pain Burning sensation in mouth Dry tongue Painful cracks in the angles of a dry mouth Pale color of the skin Less common symptoms Cold intolerance Reduced resistance to infection Altered behavior Craving for for unusual items (such as ice or cold vegetables)	Lab tests are consistent with the diagnosis of iron deficiency anemia. Findings on an x-ray (barium esophagogram) suggestive of esophageal web/strictures associated with Plummer-Vinson syndrome appear as either: Thin projections on the anterior esophageal wall. Multiple upper (cervical) esophageal constrictions consistent with esophageal webs. Plummer-Vinson syndrome (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)