Esophageal Stricture.docx

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