Esophageal Stricture Clinical Presentation

  • Author: Sandeep Mukherjee, MB, BCh, MPH, FRCPC; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 4, 2012
 

History

  • Patients with peptic strictures may present with heartburn, dysphagia, odynophagia, food impaction, weight loss, and chest pain.
  • Progressive dysphagia for solids is the most common presenting symptom. This may progress to include liquids.
  • Atypical presentations include chronic cough and asthma secondary to aspiration of food or acid.
  • The clinician cannot rely on the presence or absence of heartburn to definitely determine whether dysphagia is secondary to a peptic esophageal stricture.
    • Of patients with peptic esophageal strictures, 25% have no previous history of heartburn.
    • Heartburn may resolve with worsening of a peptic stricture.
    • Approximately two thirds of patients with adenocarcinoma in Barrett esophagus have a history of long-standing heartburn.
    • The abnormal esophageal motor activity in achalasia can produce a heartburn sensation.
  • Important points regarding dysphagia
    • The obstruction is usually 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 a Schatzki ring is usually 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 of a peptic esophageal stricture.
    • 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.
  • Determining whether the patient takes any medications known to cause pill esophagitis is important.
  • Determining whether a history of collagen vascular disease or immunosuppression exists may provide clues to the underlying etiology.
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Physical

  • Physical examination frequently does not provide clues to the cause of dysphagia.
  • Assessing the patient's nutritional status is important.
  • Patients with collagen vascular diseases may exhibit joint abnormalities, calcinosis, telangiectasias, sclerodactyly, or rashes.
  • The presence of atypical gastroesophageal reflux disease may be suggested by hoarse voice, posterior oropharyngeal erythema, diffuse dental erosions, wheezing, or epigastric tenderness.
  • Patients with adenocarcinoma of the gastroesophageal junction may have left supraclavicular lymphadenopathy (Virchow node).
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Causes

  • Proximal or mid esophageal strictures
    • Caustic ingestion (acid or alkali)
    • Malignancy
    • Radiation therapy[3, 4]
    • Infectious esophagitis -Candida, herpes simplex virus (HSV), cytomegalovirus (CMV), human immunodeficiency virus (HIV)
    • Acquired immunodeficiency syndrome (AIDS) and immunosuppression in patients who have received a transplant
    • Medication-induced stricture (pill esophagitis) - Alendronate, ferrous sulfate, nonsteroidal anti-inflammatory drugs (NSAIDs), phenytoin, potassium chloride, quinidine, tetracycline, ascorbic acid.[5] Drug-induced esophagitis often occurs at the anatomic site of narrowing, with the middle one-third behind the left atrium predominating in 75.6%.[6]
    • 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
    • Sequela of endoscopic submucosal dissection for superficial squamous cell neoplasms.[7]
    • 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 intubation
    • Crohn disease
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Contributor Information and Disclosures
Author

Sandeep Mukherjee, MB, BCh, MPH, FRCPC  Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Coauthor(s)

Rajeev Vasudeva, MD, FACG  Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association

Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

Specialty Editor Board

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF  Associate Professor of Clinical Medicine, Albert Einstein College of Medicine of Yeshiva University; Associate Professor of Clinical Medicine, Hofstra Medical School

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Simmy Bank, MD  Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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Esophageal stricture. Endoscopic appearance of the distal esophagus showing a smooth stricture with a benign appearance.
 
 
 
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