Esophageal stricture overview

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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

Medical Therapy

Surgery

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Surgical Management

Primary Prevention

Secondary Prevention

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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 esophagographyesophagogastroduodenoscopyendoscopic 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 lymphocytosisbasal cell hyperplasia in gastroesophageal reflux diseaseT 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 syndromeachalasia, diffuse esophageal spasmsystemic sclerosiszenker's diverticulumesophageal carcinomastroke, motor disorders such as Myasthenia GravisGERD, 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 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 perforationbleedingpneumonia and bacteremiaPrognosis 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 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 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 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

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.

References

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