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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 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.
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 esophageal [[carcinoma]] was performed by Vincenz Czerny. The first stent was introduced in 1990.
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 of [[esophageal]] [[stricture]], but it may be classified into [[benign]] and [[malignant]] according to causes.
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 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.
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 (medical)|infiltration]] T [[lymphocytes]] in [[squamous]] [[mucosa]] in [[lymphocytic]] [[esophagitis]] and [[eosinophilic]] [[necrosis]] in [[caustic]] ingestion
[[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 of [[esophageal]] [[stricture]] include [[gastroesophageal reflux disease]] and [[caustic]] ingestions.
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]] , [[diffuse esophageal spasm]], [[systemic sclerosis]], [[zenker's diverticulum]], [[Esophageal cancer|esophageal carcinoma]], [[stroke]], motor disorders, [[GERD]][[Esophageal web|, esophageal web]].
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 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.
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 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.
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]] for [[esophageal]] [[stricture]].
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 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.
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]].
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 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]].
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 with [[esophageal]] [[stricture]] due to [[malignant]] causes.
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 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.
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 of [[esophageal]] [[stricture]].
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 of [[esophageal]] [[stricture]].
[[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 [[esophageal]] [[stricture]].
In general [[MRI]] has not been routinely recommended for esophageal stricture.


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
Line 66: Line 66:


===Other Imaging Findings===
===Other Imaging Findings===
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.
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===
Line 73: Line 73:
==Treatment==
==Treatment==
===Medical Therapy===
===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]].
 [[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 for [[esophageal stricture]] is [[dilation]]. Self-expandable plastic or metal [[Stent|stents]] placement is indicated for patients with refractory [[esophageal]] [[stricture]].  
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]] 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.
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 of [[esophageal]] [[stricture]] include lifestyle modification, [[Proton pump inhibitor|proton pump inhibitors]] or [[Histamine-2 receptor blocker|H2 antagonists]].<gallery>
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:
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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]

Esophageal stricture Microchapters

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Esophageal stricture from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic study of choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

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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 esophagographyesophagogastroduodenoscopyendoscopic ultrasoundmanometry. 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 diseaseinfiltration 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 spasmsystemic sclerosiszenker's diverticulumesophageal carcinomastroke, 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 herniaobesitysmokingesophageal 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 aspirationweight loss, and dehydration. Common complications of esophageal stricture include perforationbleedingpneumoniabacteremiaPrognosis 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 esophagographyesophagogastroduodenoscopyendoscopic ultrasoundmanometry.

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 dysphagiaodynophagia, 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

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.

References

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