Table of Contents
- Causes of Esophageal Stricture
- Pathophysiology of Esophageal Stricture
- Epidemiology of Esophageal Stricture
- Clinical Presentation of Esophageal Stricture
- Physical Examination of Esophageal Stricture
- Diagnosis and Workup of Esophageal Stricture
- Medical Management of Esophageal Stricture
- Surgical Intervention for Esophageal Stricture
Causes of Esophageal Stricture
There are three basic conditions which may lead to the development of esophageal stricture, namely:
- Intrinsic diseases: the triggering factors for these ailments are neoplastic and inflammatory processes as well as fibrosis; all these lesions are the causes for the stenosis (narrowing) of the esophageal lumen.
- Extrinsic disease: stipulated by the enlargement of the lymphatic nodes (in cancer sufferers), which leads to the significant changes in the size of the esophageal lumen.
- Conditions that affect the peristalsis of the esophagus and its lower esophageal sphincter (LES) due to the impaired function of the smooth muscles of the organ and its innervation.
Apart from the listed above, there are certain conditions that may result in the manifestation of this disease: after-effects of chemical burns (acid or caustic); congenital; idiopathic; autoimmune; iatrogenic including medication- or radiation-induced processes.
The diagnosis of esophageal stricture can be confirmed by radiological methods, endoscopic visualization and tissue biopsy, as well as manometry if there is dysmotility suspected by a physician.
Malignant growth, which is really hard for the timely diagnostics in this part of the body, is detected with the help of CT and endoscopic ultrasonography. The majority of benign tumors of the esophagus are accessible for pharmacological, endoscopic means of examination, and surgery despite the fact that they are difficult for the performance here.
Pathophysiology of Esophageal Stricture
There are particular reasons for peptic esophageal strictures that are:
- Gastroesophageal reflux-provoked esophagitis, originating in the squamocolumnar junction with the size of 3-4 cm in the length
- The dysfunction of the lower esophageal sphincter (LES) stipulated by lower pressure in this unit of the esophagus leads to the development of peptic strictures. If there is an LES pressure of less than 8mm Hg it contributes to the procreation of peptic stricture.
- Inappropriate esophageal clearance is the sequel of the chaotic motility. 64% of patients suffering from peptic strictures had this problem with peristalsis.
- Hiatal hernia is quite common as it constitutes 10-15% of the population; 42% have reflux with no esophagitis; 63% with esophagitis; 85% of the sufferers have peptic esophageal strictures.
- Acid and pepsin do not play a pivotal role in the esophageal stricture formation as other factors do; however, some authors allege that alkaline reflux affects the mucosa of the esophagus.
- Gastric emptying may be taken into consideration, though there is no any convincing evidence about this factor as the triggering one for the condition.
Epidemiology of Esophageal Stricture
The USA statistics witness that 40% of the adult population suffers from gastroesophageal reflux; moreover, 7% to 23% of untreated patients with reflux disease are exposed to the development of esophageal stricture. Furthermore, up to 80% of esophageal strictures are the consequence of gastroesophageal reflux; after surgery strictures make up to 10%; less than 5% of all cases refer to corrosive strictures of the esophagus.
The data for the US have become more or less promising since 1989, when proton pump inhibitors (PPIs) were administered for the first time.
Age, gender and race
Whites are more susceptible to peptic strictures than colored or Asian people; there are 10 times as many sufferers amongst the former ones as in the latter group of the population. Nevertheless, this evidence is really controversial as there is relative frequency of occurrence of esophageal strictures in colored people (black and non-Hispanic whites) was detected; both had almost the same rate.
Men are more exposed to peptic strictures than women in the correlation 2:1 or 3:1.
The older the patients are, the bigger the probability of contracting the condition there is as long exposure to the acidic components of the gastric juice leads to esophageal stricture.
Clinical Presentation of Esophageal Stricture
Patients with peptic stricture may have:
- a physician has to keep in his mind that a quarter of the patients do not have this symptom;
- also, this factor may abate when the peptic stricture impairs;
- the majority of adenocarcinoma in Barrett’s esophagus complains about long-lasting heartburn;
- achalasia can be a reason of heartburn as the result of disrupted esophageal motor activity.
- especially progressive dysphagia for solids and liquids may witness for motility disorder, autoimmune disease (collagen vascular disorder)
- intermitted and non-progressive dysphagia secondary to Shatzki’s Ring;
- Obstruction occurs either above or at the place of the lesion.
- slow long-lasting dysphagia, low frequency of cases, with no or slight weight loss without rapid impairment vote for a benign type of the esophageal stricture;
- Rapid regress of the general condition, weight loss, severe course of the disease, high frequency of the occurrence are the factors determining the malignant origin of the condition.
- Food impaction
- Loss of weight
- Pain in the chest
- Atypical symptoms: a chronic cough, even asthma attacks as a secondary symptom of the food aspiration.
It is crucial to find out whether the patient was taking a regular medication at the time of the manifestation of any of the listed symptoms.
Physical Examination of Esophageal Stricture
Unfortunately, in most of the cases, physical examination is not really informative, hence, it is vital to estimate the nourishment of the patient. Collagen vascular disease may produce deformed joints, telangiectasia, various rashes, calcinosis, sclerodactyly.
The most common symptoms of gastroesophageal reflux are:
- Voice hoarseness
- Oropharyngeal erythema
- Lesions of the teeth
- Discomfort in the epigastric area
Virchow’s node (left supraclavicular lymphadenopathy) is often found in adenocarcinoma of the gastroesophageal junction.
Diagnosis and Workup of Esophageal Stricture
Complete blood cell (CBC) count
There are no significant changes in CBC apart from those cases when the disease has advanced course (bleeding from the lesions and carcinoma), then CBC may reflect the pattern of anemia.
Liver profile studies
Normally, there is no pronounced picture here; however, the liver tests may be abnormal in malignant processes with metastasis.
Complete metabolic panel
This method allows the assessment of the nutritional status of the patient with esophageal stricture especially in the case of the significant weight loss.
- Barium esophagography may be accompanied by endoscopic findings, which is more informative, however, risky in the case of diverticula and paraesophageal hernias. Also, this study is more efficient for diagnostics of latent strictures of the esophagus, which are larger than 10 mm in diameter (100% sensitivity where luminal diameter is less than 9 mm and 90% with greater than 10 mm)
- Chest radiography: this method of diagnostics is applied as an additional tool when extrinsic compression is taken into account as the reason of esophageal stricture (posteroanterior (PA) and lateral films).
- CT scan: CT is successfully administered in precise diagnostics of malignant tumors of the esophagus (82% of accuracy).
- Endoscopic ultrasound (EUS): this method is the most accurate in the diagnostics of the esophageal tumors (92% of accuracy).
- Esophagogastroduodenoscopy is more sensitive than any other methods and informative in the detection of esophageal stricture as well as esophagitis; confirmation or exclusion of malignant tumors; biopsy, brush cytology specimens and conduction of therapy for the condition.
- Twenty-four-hour esophageal pH monitoring: this study is useful in the assessment of the efficiency of the therapy with PPIs and fundoplication in those ones who still produces symptoms notwithstanding the treatment.
- Esophageal manometry: this study is used for the evaluation of the motility of the esophagus especially before the surgical intervention (antireflux).
- Histological findings: with the help of this method such symptoms may be found:
- Cellular infiltration
- Hyperplasia of the basal cells
- Vascular deformations (reflecting increase in type 3 collagen depositions on healing)
- Progressive inflammation, ulceration, damage of muscular layer and the intrinsic system when neglected.
CT (69% accuracy in the estimation of the depth of tumor, 82% in the assessment of the spread within organs) and EUS (92% accuracy in the assessment of the depth of lesions) are informative in detecting the stages of the malignant growth.
Medical Management of Esophageal Stricture
- Mechanical dilatation
- Administration of PPIs for the suppression of the acid
- Omeprazole 20mg/d is more efficient than ranitidine 300 mg twice a day (Smith et al.)
- Redelation percentage in the patients treated with omeprazole 20-40 mg/d was 41% in comparison to 73% who were taking ranitidine 150-300mg twice per day (Marks et al.)
- PPI treatment is cheaper than the one with H2 blocker drugs.
Surgical Intervention for Esophageal Stricture
- Delation via endoscopic examination
- Intralesional steroid injection
- Endoscopic stricturoplasty
- Pharyngoesophageal puncture
- Expandable polyester silicone-covered stent