Esophageal stricture

Esophageal stricture refers to any persistent intrinsic narrowing of the esophagus. 

Terminology

The term peptic stricture refers specifically to those benign esophageal strictures caused by chronic acid reflux, although some - incorrectly - use it more loosely to refer to any benign esophageal narrowing. The qualifying word "esophageal" is usually omitted as strictures due to acid elsewhere in the gut are very rare ^5,6. 

Epidemiology

Associations

Esophageal strictures are often associated with a hiatal hernia.

Pathology

Etiology

The most common causes are fibrosis induced by inflammatory and neoplastic processes. Because radiographic findings are not reliable in differentiating benign from malignant strictures, all should be evaluated endoscopically. 

Upper and middle esophageal strictures

These most commonly result from:

• Barrett esophagus

• mediastinal radiation

• caustic ingestion

• congenital esophageal stenosis

• esophageal intramural pseudodiverticulosis

• skin diseases associated with mucosal ulceration, such as 

  • pemphigoid

  • erythema multiforme

  • epidermolysis bullosa dystrophica

Distal esophageal strictures

These are typically caused by gastro-esophageal reflux disease (GERD), either as a separate entity or in the setting of:

• scleroderma

• prolonged nasogastric intubation

• Zollinger-Ellison syndrome: high acidity reflux

• post partial or total gastrectomy: alkaline reflux

  • performing the Roux-en-Y procedure may avoid this, by diverting the pancreatic secretions and bile away from the gastric remnant

As stated earlier if reflux disease has been a significant contributor to the development of the stricture then using the term "peptic stricture" is appropriate.

Radiographic features

Benign strictures characteristically:

• smoothly tapering

• typically concentric narrowing, but may affect only one side of the esophagus (asymmetric wall rigidity)

Malignant strictures are characteristically:

• abrupt

• asymmetric

• eccentric with irregular, nodular mucosa

Tapered margins may occur with malignant lesions because of the ease of submucosal spread of a tumor.

Treatment and prognosis

The risk of Barrett esophagus in stricture is 20-40% and strictures should be evaluated endoscopically. 

Benign esophageal strictures are typically treated with dilation, providing symptomatic relief, however recurrent strictures do occur. Complex strictures (length >2 cm, tortuous) are more likely to be recurrent. Treatment of malignant strictures involves treating the underlying cause. In palliative strictures, stent placement and brachytherapy play a role ⁴.

Differential diagnosis

• oesphageal web

• oesphageal achalasia

• diffuse oesphageal spasm

• Schatzki ring