Carcinoma of the cervical esophagus extending into the post cricoid esophagus.
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 compromise 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.
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 compromise 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. These include acid peptic, autoimmune, infectious, caustic, congenital, iatrogenic, medication-induced, radiation-induced, malignant, and idiopathic disease processes.
Important points regarding dysphagia
The obstruction usually is perceived at a point that is either above or at the level of the lesion.
Dysphagia for solids and liquids simultaneously should alert the clinician to the possibility of a motility disorder such as achalasia or collagen vascular disorders.
Dysphagia secondary to Schatzki ring usually is intermittent and nonprogressive.
Dysphagia for solids and liquids early in the course of disease should alert the clinician to the possibility of achalasia as an etiology.
Benign esophageal strictures usually produce dysphagia with slow and insidious progression (ie, months to years) of frequency and severity with minimal weight loss.
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.
Causes of Esophageal stricture:
Proximal or mid esophageal strictures
Caustic ingestion (acid or alkali)
Malignancy
Radiation therapy
Infectious esophagitis - Candida, herpes simplex virus (HSV), cytomegalovirus (CMV), HIV
AIDS and immunosuppression in patients who have received a transplant
Medication-induced stricture (pill esophagitis) - Alendronate, ferrous sulfate, nonsteroidal anti-inflammatory drugs, phenytoin, potassium chloride, quinidine, tetracycline, ascorbic acid
Diseases of the skin - Pemphigus vulgaris, benign mucous membrane (cicatricial) pemphigoid, epidermolysis bullosa dystrophica
Graft versus host disease
Idiopathic eosinophilic esophagitis
Extrinsic compression
Squamous cell carcinoma
Miscellaneous - Trauma to the esophagus from external forces, foreign body, surgical anastomosis/postoperative stricture, congenital esophageal stenosis
Distal esophageal strictures
Peptic stricture - Gastroesophageal reflux disease, Zollinger-Ellison syndrome
Adenocarcinoma
Collagen vascular disease - Scleroderma, systemic lupus erythematosus (SLE), rheumatoid arthritis
Extrinsic compression
- Alkaline reflux following gastric resection
Sclerotherapy and prolonged nasogastric intubatio
Crohn disease
Imaging Studies:
Barium esophagram
Barium esophagram provides an objective baseline record of the esophagus prior to medical therapy or endoscopic intervention.
This study also provides information about the location, length, and diameter of the stricture and the smoothness or irregularity of the esophageal wall (road map).
The information obtained can complement endoscopic findings.
Lesions, such as diverticula and paraesophageal hernias, that potentially may lead to increased risk of complications during endoscopy can be identified.
This study may be more sensitive than endoscopy for detection of subtle narrowings of the esophagus such as those caused by rings and peptic strictures that are greater than 10 mm in diameter.
This study has 100% sensitivity with luminal diameter less than 9 mm, and 90% sensitivity with luminal diameter greater than 10 mm.
Chest radiograph, posteroanterior (PA) and lateral: Chest radiography should be used as an adjunct if extrinsic compression is considered a possible etiology of esophageal stricture.
Computed tomography scan
CT scan can be used to stage malignancies that produce esophageal strictures.
Accuracy in estimating the depth of tumor invasion is 60-69%.
Accuracy in determining spread to other organs is 82%.
Endoscopic ultrasound
Endoscopic ultrasound (EUS) is the most accurate means of identifying the extent of local invasion of an esophageal malignancy.
- Accuracy in estimating the depth of tumor invasion in the esophagus is 92%.