Esophageal strictures

Etiology of Esophageal Stricture

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Intrinsic Diseases

• Gastroesophageal Reflux Disease (GERD): The most common intrinsic cause, accounting for 70-80% of adult cases. Chronic reflux of stomach acid into the esophagus leads to inflammation, scarring, and eventually narrowing.
• Eosinophilic Esophagitis: An allergic inflammatory condition causing esophageal narrowing.
• Radiation Therapy: Can induce inflammation and scarring, leading to stricture.
• Esophageal Varices Treatment: Procedures like banding or sclerotherapy may result in injury and stricture.
• Caustic Ingestions: Corrosive substance ingestion leads to severe injury and stricture.
• Esophageal Surgeries: Post-operative scarring can cause stricture.
• Nasogastric Tube Use: Frequent use may cause injury and stricture.
• Dermatologic Diseases: Rare conditions involving the esophagus.
• Congenital Factors: Esophageal strictures and webs present from birth.

Extrinsic Diseases

• Malignancies and Lymph Node Enlargement: Direct invasion or lymph node enlargement can compress the esophagus, causing stricture.

Disorders Affecting Esophageal Motility

• Conditions that disrupt esophageal movement and lower esophageal sphincter function.

Pathogenesis of Esophageal Stricture

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Inflammation and Fibrosis

• GERD: Chronic regurgitation of gastric contents into the esophagus leads to inflammation and fibrosis of the esophageal mucosa, causing stricture. Contributing factors include esophageal dysmotility, lower esophageal sphincter (LES) tone impairment, transient LES relaxation, and delayed gastric emptying.
• Eosinophilic Esophagitis (EoE): A chronic, T helper type 2 (Th2)–associated inflammatory disease marked by eosinophilic inflammation. Its pathogenesis involves environmental and genetic factors, with roles for eosinophils, mast cells, and cytokines like IL-5 and IL-13, often triggered by allergic sensitization to foods.
• Caustic Ingestion: Ingesting toxic substances (like lye) severely damages the esophageal mucosa, leading to inflammation, necrosis, and subsequent fibrosis and stricture.

Neoplasia

• Tumor Growth: Abnormal cell growth can cause stricture either through direct invasion of the esophageal lumen or extrinsic compression by enlarged lymph nodes or other structures.

Other Contributing Factors

• Autoimmune Diseases
• Infectious Diseases
• Congenital Conditions
• Iatrogenic Causes (medical interventions)
• Medication-Induced Causes
• Radiation-Induced Causes
• Idiopathic Processes (unknown causes)

Epidemiology of Esophageal Stricture

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Incidence and Prevalence

• General Incidence: Esophageal stricture has an incidence rate of 1.1 per 10,000 person-years, with an increase in incidence observed with advancing age.
• Study Findings: In one study, the overall incidence was reported as 11 per 100,000 individuals, with benign strictures at 8 per 100,000 and malignant strictures at 3 per 100,000.

Impact of Diagnostic Delay

• Eosinophilic Esophagitis (EoE): The prevalence of esophageal stricture increases with delayed diagnosis, ranging from 17% within 0-2 years to 71% after 20 years.

Age-Related Variations

• Children and Young Patients: Higher incidence of strictures due to caustic esophagitis or eosinophilic esophagitis.
• Adults: Acid reflux, iatrogenic, or drug-induced esophagitis are more common causes.
• Older Populations: Increased incidence of malignant strictures due to higher cancer prevalence.

Influence of GERD

• GERD-Related Strictures: Approximately 7-23% of untreated GERD patients develop esophageal strictures.
• GERD Prevalence: Affects about 40% of adults, with strictures in 7–23% of untreated cases.
• Impact of Proton Pump Inhibitors: The incidence of benign esophageal stricture has decreased due to PPI use in GERD treatment.

Gender and Racial Distribution

• Gender Differences: Higher risk in men under 60 years, but similar incidence in men and women after age 60.
• Racial Predilection: No racial predilection has been identified for esophageal stricture.

Signs and Symptoms of Esophageal Stricture

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Common Symptoms

• Dysphagia: Difficulty swallowing is the most common symptom.
• Odynophagia: Painful swallowing.
• Regurgitation: Food coming back up the throat from the stomach.
• Heartburn: Frequent occurrence.
• Throat Inflammation: Burning sensation in the throat.
• Hiccupping/Burping: Frequent episodes.
• Coughing/Choking: Especially during eating.
• Weight Loss: Unintentional, due to difficulty in swallowing.
• Drooling: Inability to swallow saliva efficiently.
• Dehydration: Due to difficulty in swallowing liquids.

Diagnosis of Esophageal Stricture

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Initial Evaluation

• Medical History: Understanding symptoms like dysphagia, food sticking sensation, and heartburn.
• Physical Examination: Bedside evaluation for signs indicative of esophageal stricture.

Diagnostic Tests

• Esophagogastroduodenoscopy (EGD): A flexible tube with a camera is used to visualize the esophagus, stomach, and duodenum. It helps identify the stricture’s presence and location. Biopsies can be performed if needed.
• Contrast-enhanced Esophagogram or Barium Swallow: Patient swallows a barium solution to coat the esophagus, making it visible on X-rays. This shows the size and location of the stricture.
• Esophageal Manometry: Measures esophageal muscle pressure and coordination, detecting irregular peristalsis or muscle contractions.
• Endoscopic Ultrasound (EUS): Useful particularly when biopsies are negative for malignancy but there’s suspicion of esophageal cancer.

Assessment of Esophageal Motility Disorders

• It’s important to evaluate for any associated esophageal motility disorders, as they can influence the management approach for esophageal strictures.

Differential Diagnosis of Esophageal Stricture

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Key Conditions to Consider

• Achalasia: A disorder affecting esophageal motility and relaxation of the lower esophageal sphincter.
• Esophageal Motility Disorders: Abnormal muscle contractions in the esophagus causing dysphagia.
• Esophagitis: Inflammation of the esophagus, which can mimic symptoms of stricture.
• Schatzki Ring: A thin ring of tissue in the lower esophagus that can cause swallowing difficulties.
• Plummer-Vinson Syndrome: Characterized by iron deficiency anemia, dysphagia, and esophageal webs.
• Diffuse Esophageal Spasm: Intermittent contractions of the esophagus leading to swallowing issues.
• Systemic Sclerosis: An autoimmune disease that can involve esophageal dysfunction.
• Zenker’s Diverticulum: A pouch that can form in the throat, near the esophagus, causing swallowing difficulties.
• Esophageal Carcinoma: Cancer of the esophagus, presenting with progressive dysphagia.
• Stroke: Neurological event that can affect swallowing.
• Motor Disorders: Such as Myasthenia Gravis, affecting muscle strength and function.
• Gastroesophageal Reflux Disease (GERD): Chronic acid reflux causing esophageal irritation.
• Esophageal Web: Thin membranes across the esophagus, causing obstruction.

Treatment Options for Esophageal Stricture

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Esophageal Dilation

• Procedure: Widening the narrowed area using a balloon or dilator.
• Method: Placement of the dilator using an endoscope, often performed during endoscopy.

Steroid Injections

• Purpose: To reduce inflammation and prevent recurrence of the stricture.
• Application: Administered alongside dilation procedures.

Stent Placement

• Use: Primarily for palliation of malignant esophageal strictures.
• Function: Keeps the esophagus open to facilitate swallowing, suited for patients with limited expected survival.

Incisional Therapy

• Indication: For refractory strictures that do not respond to dilation.
• Method: Cutting scar tissue to open the stricture.

Surgical Resection

• Consideration: In cases involving cancer, to remove cancerous tissue.
• Goal: To alleviate the stricture caused by tumor growth.

Medical Management

• Treatment: Use of proton pump inhibitors (PPIs) for underlying conditions like GERD.
• Objective: To prevent further damage and recurrence of the stricture.