esophageal stricture

Preschooler

with reflux. Lateral spot image from an upper GI shows multiple small ulcerations in the esophageal mucosa and a fixed tight narrowing of the distal esophagus in the middle of the image which never opened up during the exam. Gastroesohageal reflux was also demonstrated throughout the examThe diagnosis was a distal esophageal stricture due to esophagitis from gastroesophageal reflux.

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Imaging of

the oesophagus: beyond cancer. Stricture. Esophagram in left posterior oblique (LPO) projection shows an irregular short segment narrowing within the distal oesophagus consistent with a stricture. There is oesophageal dilatation proximal to the stricture

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

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

Associations

Esophageal strictures are often associated with a hiatal hernia.

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 .