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esophageal stricture

Etiology: - gastric acid (peptic) esophagitis a) gastroesophageal reflux (GERD) (70%) b) Zollinger-Ellison - connective tissue disorders - scleroderma - systemic lupus erythematosus (SLE), rheumatoid arthritis - graft versus host disease - Crohn's disease - infectious disease: a) esophageal candidiasis b) herpes simplex virus c) cytomegalovirus (CMV) d) HIV1 - diseases of the skin a) pemphigus vulgaris b) cicatricial pemphigoid c) epidermolysis bullosa dystrophica - ingestions of caustic agents (acid or alkali) - congenital disorders - iatrogenic disorders a) sclerotherapy b) prolonged nasogastric intubation - medication-induced: - alendronate, ferrous sulfate, NSAIDs, phenytoin, KCl, quinidine, tetracycline, ascorbic acid - radiation exposure - malignancies - idiopathic eosinophilic esophagitis - idiopathic Epidemiology: - 10-fold more common in whites than blacks or Asians - 2-3-fold more common in men than in women - patients tend to be older, with longer duration GERD Pathology: - intrinsic esophageal pathology can narrow the esophageal lumen via inflammation, fibrosis, or neoplasia - extrinsic pathology can compress the esophageal lumen by direct invasion or lymph node enlargement - disorders of esophageal peristalsis &/or the lower esophageal sphincter can narrow the esophageal lumen via effects on esophageal smooth muscle & its innervation Clinical manifestations: - progressive dysphagia for solids is the most common presenting symptom; may progress to include liquids - heartburn, dysphagia, odynophagia, food impaction, weight loss, chest pain may be present - chronic cough & asthma due to aspiration of food or acid less common Special laboratory: - EGD with tissue biopsy - esophageal mannography when dysmotility is suspected Radiology: - barium swallow may be an appropriate initial test - computed tomography may be useful for assessing extrinsic pathology - esophageal ultrasound may be useful for assessing extrinsic pathology Differential diagnosis: - obstruction is generally perceived at a point either above or at the level of the lesion - dysphagia for solids & liquids simultaneously suggests a motility disorder, i.e. achalasia, connective tissue disorder - dysphagia secondary to Schatzki ring is generally intermittent & nonprogressive - benign esophageal strictures usually produce dysphagia with slow & insidious progression (months to years) & minimal weight loss - malignant esophageal strictures usually produce a rapid progression (weeks to months) & significant weight loss Management: - treatment of GERD - esophageal dilation - investigational procedures a) endoscopic stricturoplasty b) esophageal stent - self-expanding metal stent for malignant esphageal stricture - other surgical procedures

General

stricture esophageal disease

References

  1. Vasudeva R Esophageal Stricture eMedicine http://emedicine.medscape.com/article/175098-overview
  2. Wikipedia: Esophageal stricture http://en.wikipedia.org/wiki/Esophageal_stricture
  3. Smith CD. Esophageal strictures and diverticula. Surg Clin North Am. 2015 Jun;95(3):669-81. Review. PMID: 25965138