Esophageal Stricture.docx

1、Esophageal StrictureEsophageal StrictureINTRODUCTION Background: Disease processes that can produce esophageal strictures can be grouped into 3 general categories: (1) intrinsic diseases that narrow the esophageal lumen through inflammation, fibrosis, or neoplasia; (2) extrinsic diseases that compro

2、mise the esophageal lumen by direct invasion or lymph node enlargement; and (3) diseases that disrupt esophageal peristalsis and/or lower esophageal sphincter (LES) function by their effects on esophageal smooth muscle and its innervation. Many diseases can cause esophageal stricture formation. Thes

3、e include acid peptic, autoimmune, infectious, caustic, congenital, iatrogenic, medication-induced, radiation-induced, malignant, and idiopathic disease processes. The etiology of esophageal stricture can usually be identified using radiologic and endoscopic modalities and can be confirmed by endosc

4、opic visualization and tissue biopsy. Use of manometry can be diagnostic when dysmotility is suspected as the primary process. CT scan and endoscopic ultrasound are valuable aids in the staging of malignant stricture. Fortunately, most benign esophageal strictures are amenable to pharmacological, en

5、doscopic, and/or surgical interventions. Because peptic strictures account for 70-80% of all cases of esophageal stricture, peptic stricture is the focus of this article. A detailed discussion of possible benign and malignant processes associated with esophageal stricture and its management is beyon

6、d the scope of this article. Pathophysiology: Peptic strictures are sequelae of gastroesophageal refluxinduced esophagitis, and they usually originate from the squamocolumnar junction and average 1-4 cm in length. Two major factors involved in the development of a peptic stricture are as follows: o

7、Dysfunctional lower esophageal sphincter: Mean LES pressures are lower in patients with peptic strictures compared with healthy controls or patients with milder degrees of reflux disease. A study by Ahtaridis et al (1979) showed that patients with peptic strictures had a mean LES pressure of 4.9 mm

8、Hg versus 20 mm Hg in control patients. LES pressure of less than 8 mm Hg appeared to correlate significantly with the presence of peptic esophageal stricture without any overlap in controls. o Disordered motility resulting in poor esophageal clearance: In the same study, Ahtaridis et al (1979) demo

9、nstrated that 64% of patients with strictures had motility disorders compared with 32% of patients without strictures. Other possible associated factors include the following: o Presence of a hiatal hernia: Hiatal hernias are found in 10-15% of the general population, 42% of patients with reflux sym

10、ptoms and no esophagitis, 63% of patients with esophagitis, and 85% of patients with peptic strictures. This suggests that hiatal hernias may play a significant role. o Acid and pepsin secretion: This does not appear to be a major factor. Patients with peptic strictures have been demonstrated to hav

11、e the same acid and pepsin secretion rates as gender-matched and age-matched controls with esophagitis but no stricture formation. In fact, some authors believe that alkaline reflux may play an important role. o Gastric emptying: No good evidence suggests that delayed emptying plays a role. Frequenc

12、y: In the US: Gastroesophageal reflux affects approximately 40% of adults. Strictures are estimated to occur in 7-23% of untreated patients with reflux disease. Gastroesophageal reflux disease accounts for approximately 70-80% of all cases of esophageal stricture. Postoperative strictures account fo

13、r about 10%, and corrosive strictures account for less than 5%. The overall frequency of initial and subsequent dilations for peptic stricture appears to have decreased gradually since the introduction of proton pump inhibitors (PPIs) in the market in 1989. This has been borne out by data at the aut

14、hors institution and in 2 large community hospitals in Wisconsin. It is also in keeping with the general experience of gastroenterologists in the United States. Mortality/Morbidity: The mortality rate is not increased unless a procedure-related perforation occurs or the stricture is malignant. Howev

15、er, the morbidity for peptic strictures is significant. Most patients undergo a chronic relapsing course with an increased risk of food impaction and pulmonary aspiration. Frequently, coexistent Barrett esophagus and its attendant complications occur. The need for repeated dilatation potentially inc

16、reases the risk of perforation. Race: Peptic strictures are 10-fold more common in whites than African Americans or Asians. Sex: Peptic strictures are 2- to 3-fold more common in men than in women. Age: Patients tend to be older, with a longer duration of reflux symptoms. CLINICAL History: Patients

17、may present with heartburn, dysphagia, odynophagia, food impaction, weight loss, and chest pain. Progressive dysphagia for solids is the most common presenting symptom. This may progress to include liquids. Atypical presentations include chronic cough and asthma secondary to aspiration of food or ac

18、id. The clinician cannot rely on the presence or absence of heartburn to definitely determine whether dysphagia is secondary to a peptic esophageal stricture.o Of patients with peptic esophageal strictures, 25% have no previous history of heartburn.o Heartburn may resolve with worsening of a peptic

19、stricture.o Approximately two thirds of patients with adenocarcinoma in Barrett esophagus have a history of long-standing heartburn.o The abnormal esophageal motor activity in achalasia can produce a heartburn sensation. Important points regarding dysphagiao The obstruction usually is perceived at a

20、 point that is either above or at the level of the lesion.o Dysphagia for solids and liquids simultaneously should alert the clinician to the possibility of a motility disorder such as achalasia or collagen vascular disorders.o Dysphagia secondary to Schatzki ring usually is intermittent and nonprog

21、ressive.o Dysphagia for solids and liquids early in the course of disease should alert the clinician to the possibility of achalasia as an etiology.o Benign esophageal strictures usually produce dysphagia with slow and insidious progression (ie, months to years) of frequency and severity with minima

22、l weight loss.o Malignant esophageal strictures result in a rapid progression (ie, weeks to months) of severity and frequency of dysphagia and are associated frequently with significant weight loss. Determining whether the patient takes any medications known to cause pill esophagitis is important. D

23、etermining whether a history of collagen vascular disease or immunosuppression exists may provide clues to the underlying etiology.Physical: Physical examination frequently does not provide clues to the cause of dysphagia. Assessing the patients nutritional status is important. Patients with collage

24、n vascular diseases may exhibit joint abnormalities, calcinosis, telangiectasias, sclerodactyly, or rashes. The presence of atypical gastroesophageal reflux disease may be suggested by hoarse voice, posterior oropharyngeal erythema, diffuse dental erosions, wheezing, or epigastric tenderness. Patien

25、ts with adenocarcinoma of the gastroesophageal junction may have left supraclavicular lymphadenopathy (Virchow node).Causes: Proximal or mid esophageal strictureso Caustic ingestion (acid or alkali)o Malignancyo Radiation therapyo Infectious esophagitis - Candida, herpes simplex virus (HSV), cytomeg

26、alovirus (CMV), HIVo AIDS and immunosuppression in patients who have received a transplanto Medication-induced stricture (pill esophagitis) - Alendronate, ferrous sulfate, nonsteroidal anti-inflammatory drugs, phenytoin, potassium chloride, quinidine, tetracycline, ascorbic acido Diseases of the ski

27、n - Pemphigus vulgaris, benign mucous membrane (cicatricial) pemphigoid, epidermolysis bullosa dystrophicao Graft versus host diseaseo Idiopathic eosinophilic esophagitiso Extrinsic compressiono Squamous cell carcinomao Miscellaneous - Trauma to the esophagus from external forces, foreign body, surg

28、ical anastomosis/postoperative stricture, congenital esophageal stenosis Distal esophageal strictureso Peptic stricture - Gastroesophageal reflux disease, Zollinger-Ellison syndromeo Adenocarcinomao Collagen vascular disease - Scleroderma, systemic lupus erythematosus (SLE), rheumatoid arthritiso Ex

29、trinsic compressiono Alkaline reflux following gastric resection o Sclerotherapy and prolonged nasogastric intubationo Crohn diseaseDIFFERENTIALS Achalasia Esophageal Motility Disorders Esophagitis Schatzki Ring Other Problems to be Considered: Esophageal malignancy WORKUP Lab Studies: CBC: Usually,

30、 the results on CBC are within the reference range; however, anemia may develop due to chronic bleeding from severe esophagitis or carcinoma. Liver profile: Usually, the findings are within the reference range; however, the findings may be abnormal if metastatic disease in underlying malignancy is p

31、resent. Complete metabolic panel: This may allow assessment of the nutritional status, especially in conjunction with weight loss.Imaging Studies: Barium esophagramo Barium esophagram provides an objective baseline record of the esophagus prior to medical therapy or endoscopic intervention.o This st

32、udy also provides information about the location, length, and diameter of the stricture and the smoothness or irregularity of the esophageal wall (road map).o The information obtained can complement endoscopic findings.o Lesions, such as diverticula and paraesophageal hernias, that potentially may lead to increased risk of complications during endoscopy can be identified.o This study may be more sensitive than endoscopy for detection of subtle narrowings of the e