Esophageal Stricture

Aka: Esophageal Stricture

1. Definitions
   1. Esophageal Stricture
      1. Abnormal narrowing of the esophageal lumen
2. Epidemiology
   1. Incidence: 1.1 per 10,000
   2. Ten times more common in white patients than black or asian patients
3. Pathophysiology
   1. Narrowing in the esophageal lumen due to inflammation, neoplasm, fibrosis or injury
   2. Dysphagia occurs when esophagus narrows to <13 mm from normal 20 mm size in adults
4. Risk Factors
   1. Gastroesophageal Reflux Disease
   2. Hiatal Hernia
   3. Peptic Ulcer Disease
   4. Alcohol Use
   5. Dysphagia past medical history
5. Causes
   1. Neoplasm (e.g. Esophageal Cancer)
   2. Gastroesophageal Reflux (GERD)
      1. Benign peptic strictures form with longstanding GERD
      2. Responsible for up to 70% of Esophageal Strictures in adults
   3. Injury
      1. Post-procedural Esophageal Stricture (e.g. upper endoscopy)
      2. Ingested hot or toxic liquid or solid (e.g. corrosive liquid ingestion in children)
      3. Radiation Therapy (cervical and thoracic regions)
      4. Prolonged Nasogastric Tube or Orogastric Tube
   4. Eosinophilic Esophagitis
      1. Higher risk of stricture with prolonged untreated disease
   5. Pill Esophagitis (e.g. NSAIDs, Doxycycline)
      1. Prolonged use of causative medications
   6. Viral Infections (esp. immunocompromised)
      1. Cytomegalovirus (CMV)
      2. Herpes Simplex Virus (HSV)
      3. Human Immunodeficiency Virus (HIV)
      4. Esophageal Candidiasis
   7. Miscellaneous
      1. Collagen Vascular Disease
      2. Esophageal Ring or Esophageal Web
      3. Crohn Disease
      4. Tuberculosis
6. Symptoms
   1. Solid food Dysphagia (may progress to liquid Dysphagia)
   2. Food impaction
   3. Odynophagia
   4. Chest Pain
   5. Weight loss
7. Differential Diagnosis
   1. See Esophageal Dysphagia
   2. External esophageal compression (e.g. thoracic mass)
   3. Esophageal Spasm
   4. Achalasia
   5. Esophageal Cancer
8. Diagnosis
   1. Upper Endoscopy (EGD) is preferred
      1. Allows for direct visualization and biopsy
      2. Endoscopic Ultrasound may be performed to evaluate lesion depth
   2. Barium swallow
      1. May be considered when upper endoscopy is not readily available
      2. Test Sensitivity: 95% for Esophageal Stricture
   3. Other imaging
      1. Chest XRay or CT Chest
         1. Consider for excluding alternative diagnoses (e.g. external compression)
9. Grading: Dysphagia Scoring System
   1. Score 0: No Dysphagia
   2. Score 1: Moderate passage - able to eat some solid food
   3. Score 2: Poor passage - able to eat only semi-solid food
   4. Score 3: Very poor passage - able to swallow only liquids
   5. Score 4: No passage - unable to swallow anything
10. Management
    1. First-line measures
       1. Esophageal Dilation (push/bougie or balloon)
       2. Intralesional Corticosteroid (adjunctive to dilation, refractory cases)
    2. Refractory case measures
       1. Esophageal Stent such as self-expanding metal stent or SEMS (esp. in malignancy)
       2. Surgical resection (esp. in malignancy)
    3. Maintenance management
       1. Proton Pump Inhibitor (PPI, e.g. Omeprazole) longterm use
11. Complications
    1. Food Impaction
    2. Aspiration
    3. Esophageal Perforation
    4. Esophageal fistula
12. References
    1. Moustarah (2020) StatPearls, accessed 9/24/20
    2. Pasha (2014) Gastrointest Endosc 79(2): 191-201 [PubMed]