Esophageal Stricture.docx
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Esophageal Stricture.docx
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EsophagealStricture
EsophagealStricture
INTRODUCTION
Background:
Diseaseprocessesthatcanproduceesophagealstricturescanbegroupedinto3generalcategories:
(1)intrinsicdiseasesthatnarrowtheesophageallumenthroughinflammation,fibrosis,orneoplasia;
(2)extrinsicdiseasesthatcompromisetheesophageallumenbydirectinvasionorlymphnodeenlargement;and(3)diseasesthatdisruptesophagealperistalsisand/orloweresophagealsphincter(LES)functionbytheireffectsonesophagealsmoothmuscleanditsinnervation.
Manydiseasescancauseesophagealstrictureformation.Theseincludeacidpeptic,autoimmune,infectious,caustic,congenital,iatrogenic,medication-induced,radiation-induced,malignant,andidiopathicdiseaseprocesses.
Theetiologyofesophagealstricturecanusuallybeidentifiedusingradiologicandendoscopicmodalitiesandcanbeconfirmedbyendoscopicvisualizationandtissuebiopsy.Useofmanometrycanbediagnosticwhendysmotilityissuspectedastheprimaryprocess.CTscanandendoscopicultrasoundarevaluableaidsinthestagingofmalignantstricture.Fortunately,mostbenignesophagealstricturesareamenabletopharmacological,endoscopic,and/orsurgicalinterventions.
Becausepepticstricturesaccountfor70-80%ofallcasesofesophagealstricture,pepticstrictureisthefocusofthisarticle.Adetaileddiscussionofpossiblebenignandmalignantprocessesassociatedwithesophagealstrictureanditsmanagementisbeyondthescopeofthisarticle.
Pathophysiology:
Pepticstricturesaresequelaeofgastroesophagealreflux–inducedesophagitis,andtheyusuallyoriginatefromthesquamocolumnarjunctionandaverage1-4cminlength.
∙Twomajorfactorsinvolvedinthedevelopmentofapepticstrictureareasfollows:
oDysfunctionalloweresophagealsphincter:
MeanLESpressuresarelowerinpatientswithpepticstricturescomparedwithhealthycontrolsorpatientswithmilderdegreesofrefluxdisease.AstudybyAhtaridisetal(1979)showedthatpatientswithpepticstrictureshadameanLESpressureof4.9mmHgversus20mmHgincontrolpatients.LESpressureoflessthan8mmHgappearedtocorrelatesignificantlywiththepresenceofpepticesophagealstricturewithoutanyoverlapincontrols.
oDisorderedmotilityresultinginpooresophagealclearance:
Inthesamestudy,Ahtaridisetal(1979)demonstratedthat64%ofpatientswithstrictureshadmotilitydisorderscomparedwith32%ofpatientswithoutstrictures.
∙Otherpossibleassociatedfactorsincludethefollowing:
oPresenceofahiatalhernia:
Hiatalherniasarefoundin10-15%ofthegeneralpopulation,42%ofpatientswithrefluxsymptomsandnoesophagitis,63%ofpatientswithesophagitis,and85%ofpatientswithpepticstrictures.Thissuggeststhathiatalherniasmayplayasignificantrole.
oAcidandpepsinsecretion:
Thisdoesnotappeartobeamajorfactor.Patientswithpepticstrictureshavebeendemonstratedtohavethesameacidandpepsinsecretionratesasgender-matchedandage-matchedcontrolswithesophagitisbutnostrictureformation.Infact,someauthorsbelievethatalkalinerefluxmayplayanimportantrole.
oGastricemptying:
Nogoodevidencesuggeststhatdelayedemptyingplaysarole.
Frequency:
∙IntheUS:
Gastroesophagealrefluxaffectsapproximately40%ofadults.Stricturesareestimatedtooccurin7-23%ofuntreatedpatientswithrefluxdisease.
Gastroesophagealrefluxdiseaseaccountsforapproximately70-80%ofallcasesofesophagealstricture.Postoperativestricturesaccountforabout10%,andcorrosivestricturesaccountforlessthan5%.
Theoverallfrequencyofinitialandsubsequentdilationsforpepticstrictureappearstohavedecreasedgraduallysincetheintroductionofprotonpumpinhibitors(PPIs)inthemarketin1989.Thishasbeenborneoutbydataattheauthor'sinstitutionandin2largecommunityhospitalsinWisconsin.ItisalsoinkeepingwiththegeneralexperienceofgastroenterologistsintheUnitedStates.
Mortality/Morbidity:
Themortalityrateisnotincreasedunlessaprocedure-relatedperforationoccursorthestrictureismalignant.However,themorbidityforpepticstricturesissignificant.
∙Mostpatientsundergoachronicrelapsingcoursewithanincreasedriskoffoodimpactionandpulmonaryaspiration.
∙Frequently,coexistentBarrettesophagusanditsattendantcomplicationsoccur.
∙Theneedforrepeateddilatationpotentiallyincreasestheriskofperforation.
Race:
Pepticstricturesare10-foldmorecommoninwhitesthanAfricanAmericansorAsians.
Sex:
Pepticstricturesare2-to3-foldmorecommoninmenthaninwomen.
Age:
Patientstendtobeolder,withalongerdurationofrefluxsymptoms.
CLINICAL
History:
∙Patientsmaypresentwithheartburn,dysphagia,odynophagia,foodimpaction,weightloss,andchestpain.
∙Progressivedysphagiaforsolidsisthemostcommonpresentingsymptom.Thismayprogresstoincludeliquids.
∙Atypicalpresentationsincludechroniccoughandasthmasecondarytoaspirationoffoodoracid.
∙Thecliniciancannotrelyonthepresenceorabsenceofheartburntodefinitelydeterminewhetherdysphagiaissecondarytoapepticesophagealstricture.
oOfpatientswithpepticesophagealstrictures,25%havenoprevioushistoryofheartburn.
oHeartburnmayresolvewithworseningofapepticstricture.
oApproximatelytwothirdsofpatientswithadenocarcinomainBarrettesophagushaveahistoryoflong-standingheartburn.
oTheabnormalesophagealmotoractivityinachalasiacanproduceaheartburnsensation.
∙Importantpointsregardingdysphagia
oTheobstructionusuallyisperceivedatapointthatiseitheraboveoratthelevelofthelesion.
oDysphagiaforsolidsandliquidssimultaneouslyshouldalertthecliniciantothepossibilityofamotilitydisordersuchasachalasiaorcollagenvasculardisorders.
oDysphagiasecondarytoSchatzkiringusuallyisintermittentandnonprogressive.
oDysphagiaforsolidsandliquidsearlyinthecourseofdiseaseshouldalertthecliniciantothepossibilityofachalasiaasanetiology.
oBenignesophagealstricturesusuallyproducedysphagiawithslowandinsidiousprogression(ie,monthstoyears)offrequencyandseveritywithminimalweightloss.
oMalignantesophagealstricturesresultinarapidprogression(ie,weekstomonths)ofseverityandfrequencyofdysphagiaandareassociatedfrequentlywithsignificantweightloss.
∙Determiningwhetherthepatienttakesanymedicationsknowntocausepillesophagitisisimportant.
∙Determiningwhetherahistoryofcollagenvasculardiseaseorimmunosuppressionexistsmayprovidecluestotheunderlyingetiology.
Physical:
∙Physicalexaminationfrequentlydoesnotprovidecluestothecauseofdysphagia.
∙Assessingthepatient'snutritionalstatusisimportant.
∙Patientswithcollagenvasculardiseasesmayexhibitjointabnormalities,calcinosis,telangiectasias,sclerodactyly,orrashes.
∙Thepresenceofatypicalgastroesophagealrefluxdiseasemaybesuggestedbyhoarsevoice,posteriororopharyngealerythema,diffusedentalerosions,wheezing,orepigastrictenderness.
∙Patientswithadenocarcinomaofthegastroesophagealjunctionmayhaveleftsupraclavicularlymphadenopathy(Virchownode).
Causes:
∙Proximalormidesophagealstrictures
oCausticingestion(acidoralkali)
oMalignancy
oRadiationtherapy
oInfectiousesophagitis-Candida,herpessimplexvirus(HSV),cytomegalovirus(CMV),HIV
oAIDSandimmunosuppressioninpatientswhohavereceivedatransplant
oMedication-inducedstricture(pillesophagitis)-Alendronate,ferroussulfate,nonsteroidalanti-inflammatorydrugs,phenytoin,potassiumchloride,quinidine,tetracycline,ascorbicacid
oDiseasesoftheskin-Pemphigusvulgaris,benignmucousmembrane(cicatricial)pemphigoid,epidermolysisbullosadystrophica
oGraftversushostdisease
oIdiopathiceosinophilicesophagitis
oExtrinsiccompression
oSquamouscellcarcinoma
oMiscellaneous-Traumatotheesophagusfromexternalforces,foreignbody,surgicalanastomosis/postoperativestricture,congenitalesophagealstenosis
∙Distalesophagealstrictures
oPepticstricture-Gastroesophagealrefluxdisease,Zollinger-Ellisonsyndrome
oAdenocarcinoma
oCollagenvasculardisease-Scleroderma,systemiclupuserythematosus(SLE),rheumatoidarthritis
oExtrinsiccompression
oAlkalinerefluxfollowinggastricresection
oSclerotherapyandprolongednasogastricintubation
oCrohndisease
DIFFERENTIALS
Achalasia
EsophagealMotilityDisorders
Esophagitis
SchatzkiRing
OtherProblemstobeConsidered:
Esophagealmalignancy
WORKUP
LabStudies:
∙CBC:
Usually,theresultsonCBCarewithinthereferencerange;however,anemiamaydevelopduetochronicbleedingfromsevereesophagitisorcarcinoma.
∙Liverprofile:
Usually,thefindingsarewithinthereferencerange;however,thefindingsmaybeabnormalifmetastaticdiseaseinunderlyingmalignancyispresent.
∙Completemetabolicpanel:
Thismayallowassessmentofthenutritionalstatus,especiallyinconjunctionwithweightloss.
ImagingStudies:
∙Bariumesophagram
oBariumesophagramprovidesanobjectivebaselinerecordoftheesophaguspriortomedicaltherapyorendoscopicintervention.
oThisstudyalsoprovidesinformationaboutthelocation,length,anddiameterofthestrictureandthesmoothnessorirregularityoftheesophagealwall(roadmap).
oTheinformationobtainedcancomplementendoscopicfindings.
oLesions,suchasdiverticulaandparaesophagealhernias,thatpotentiallymayleadtoincreasedriskofcomplicationsduringendoscopycanbeidentified.
oThisstudymaybemoresensitivethanendoscopyfordetectionofsubtlenarrowingsofthee
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