Oesophageal strictures

Section: UGI Sub-section: Oesophagus Curriculum: Curriculum, page 94

Definition

• Oesophageal luminal narrowing secondary to inflammation, fibrosis, or neoplasia
• Benign vs malignant
• Concerning if rapidly progressive
• Especially if associated weight loss

Aetiology

Extrinsic Causes

Vascular Rings

• Developmental abnormality
  • Aberrant right subclavian artery from descending aorta
    • Most common
    • Travels behind oesophagus, incomplete ring
    • Often asymptomatic, may cause posterior compression
      • “Dysphagia Lusoria”
      • Associated with non-recurrent laryngeal nerve
  • Anomalous formation of right aortic arch with left ligamentum arteriosum and resultant retro-oesophageal left subclavian artery
    • Complete ring
  • Double aortic arch
    • Fail to remodel appropriately, which results in two aortic arches both connecting the ascending and descending aortas
    • Complete ring
  • Other causes
    • Left aortic arch with a right descending aorta and right ductus arteriosus (or ligamentum)
    • Right aortic arch with a left descending aorta and left ductus arteriosus (or ligamentum)
    • Left aortic arch with an aberrant right subclavian and a right ductus arteriosus (or ligamentum)
    • Right aortic arch with mirror-image branching and a left ductus arteriosus (or ligamentum) arising from a retroesophageal dimple pointing to the left (also described as a double aortic arch with atretic left arch)
    • Right aortic arch with retroesophageal left innominate and either a left ductus arteriosus or diverticulum

Double aortic arch Right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum

Pulmonary artery sling

• Left pulmonary artery comes off right instead of main branch & courses between trachea & oesophagus
• Associated with other cardiac defects & foregut abnormalities
• All require repair to prevent tracheal or left PA stenosis

Innominate artery compression syndrome

• This syndrome occurs when the innominate (or brachiocephalic) artery originates later along the course of the transverse arch, resulting in takeoff to the left of the trachea.
• Anterior tracheal compression with associated tracheomalacia results when the aberrant innominate artery passes back to the right.

Intrinsic Causes

• Peptic strictures – most common (90%)
• Schatzki ring
• Rings
• Webs
  • Plummer-Vinson syndrome
• Others
• Anastomotic

Peptic Strictures

• Concentric lower oesophageal ring at squamo-columnar junction
• 2-10% of GORD pts
• Due to chronic inflammation & fibrosis
• Most < 1cm in length
• Management
  • Biopsy to exclude malignancy
  • Must treat reflux initially – PPI’s, anti-reflux surgery
  • Sequential dilation with 10mm balloon
    • Perforation risk 1-2%, 90% success rate
  • Division with laser of tight band
    • May reduce need for repeated dilation
  • Stent placement – temporary as needs to be removed
  • Severe strictures may require resection.

Oesophageal Ring

• Types of rings
  • A - normal smooth muscle contraction in the esophagus
  • B -  mucosal structure precisely at the squamocolumnar junction that is smooth and thin (≤5 mm in axial length). Owing to its location, a B ring is covered with squamous mucosa proximally and columnar epithelium distally
    • Esophageal rings are usually mucosal but in rare cases may be muscular due to hypertrophy of an A ring.
    • Schatzki ring, the most common type of esophageal ring, is a narrow mucosal B ring that is less than 12.5 mm in diameter
• Aetiology
  • Hiatus hernia 
    • Schatzki rings are almost always associated with a hiatal hernia. In a study of 167 patients with a Schatzki ring, a hiatal hernia was detected in 97 percent
      • Lies precisely at squamocolumnar mucosal GEJ
      • Does not have a component of true oesophageal muscle
    • Aetiology not understood
      • ? Persistent apposition of two mucosal layers & fibrosis of submucosa.
      • Almost always accompanied by a small hiatal hernia -? fibrosed proximal margin of sliding HH.
  • Eosinophilic oesophagitis
    • Schatzki rings have also been associated with eosinophilic esophagitis
    • However, more often patients with eosinophilic esophagitis have multiple proximal esophageal rings, long strictured segments, linear furrows in the mucosa, and eosinophilic abscesses that appear as white papules.
• Symptoms
  • Often asymptomatic
  • Episodic dysphagia (often large pieces of meat causing complete obstruction).
  • Often spontaneously passes after a few minutes
• Investigations
  • Barium swallow +/- endoscopy.
  • Endoscopy
    • Biospy ? eosinophilic esophagitis.
      • Dilation in patients with eosinophilic esophagitis is usually reserved for patients with rings who have not responded to medical therapy.
• Management
  • Endoscopic
    • Dilation - Large caliber bougie (≥50 French) or balloon dilator (18 to 20 mm)

Oesophageal Web

• Thin, membranous structures that partially or completely compromise lumen.
  • Only involve mucosa & part of the submucosa
• Aetiology
  • Congenital
    • Mostly lower 2/3, failure of coalescence of oesophageal vacuoles which normally leads to complete luminal patency between 25-31 days of embryologic development
    • Most likely circumferential, thick & rough
  • Acquired
    • More common, anterior cervical oesophagus, post-cricoid, thin mucosal fold
    • Associated with:
      • Plummer-Vinson Syndrome
      • Dermatological conditions
        • Bullous pemphigoid, Epidermolysis bullosa, pemphigus vulgaris, psoriasis, Stevens-Johnson syndrome
• Mostly asymptomatic. Occasional solid food dysphagia.
• Investigations
  • Barium endoscopy 1st investigation
  • Endoscopy may miss it high in the cervical oesophagus
• Management
  • Membranous disruption with endoscope or bougie or balloon dilation
  • Very rarely require surgical excision with mucosectomy
  • Slight increased risk of oesophageal cancer

Plummer-Vinson Syndrome

• also known as Paterson-Brown-Kelly Syndrome
  1. Upper oesophageal web
  2. Dysphagia
  3. Iron deficiency anaemia
     • ± associated with glossitis & angular stomatitis / cheilosis
• Risk of Oesophageal cancer or pharyngeal Squamous cell carcinoma
• Rare; mostly females
• Typically seen in
  • Edentulous, middle-aged, malnourished women with atrophic oral mucosa, glossitis, spoon-shaped fingernails & Fe deficiency anaemia

Other causes

• Eosinophilic oesophagitis
• Infection
• Crohn’s
• Neoplasia, post treatment strictures (radiotherapy, EMR etc)
  • Don’t dilate malignant stricture – just pass feeding tube and workup
    • Can stent later
• Pill-injury
  • Potassium, iron, beta-blocker, doxycycline, tetracycline, NSAIDs, bisphosphonates, quinidine
  • Stick at 2nd constriction as there is a low peristaltic wave here
• Caustic Ingestion

Clinical Presentation

• Dysphagia
• Cnce lumen <13mm, meat/bread impaction
• Regurgitate food
• Odynophagia
• Weight loss
• Recurrent respiratory symptoms
• Difficulty breathing
• Caustic injury

Investigations

• Gastroscopy
• CXR
  • Exclude pneumomediastinum/pneumothorax suggestive of perforation
• Hoarseness/stridor (caustic injury) = intubation early +/- nebulized steroids.
• Barium Swallow
  • To diagnose a Schatzki ring; place prone turned slightly to right; patient takes in a large breath as bolus reaches GEJ.
• CTA for anomalous anatomy

Management

Chronic Strictures

• Endoscopic Rx
  • Don’t bougie until see re-epithelialisation.
  • Bougie strictures even if asymptomatic – may need daily for weeks
  • Dilatation if less than 2 cm
    • Remove impacted food (don’t push through ring/obstruction – perforation risk).
    • Good for Schatzki ring, surgery not indicated unless dilatation fails or intractable reflux
  • Savary Gillard Dilation
    • Over guidewire, requires passage of endoscope beyond the stricture so wire not placed blind
    • Dilate up 3 x successive sizes, bring back for repeat if needed
    • Can assess force required for dilation
    • Must do post procedure endoscopy check
  • Ballon dilation “Through the scope dilatation”
    • Don’t need to pass the stricture, can see through the balloon,
    • Don’t need to pass pharynx repeatedly
  • Webs
    • Dilatation or piece-meal excision with biopsy forceps or laser lysis, bougie or balloon

Operative

• Slings, rings – repaired
  • If pulmonary sling not repaired get LPA narrowing & tracheal stenosis
  • Need open sternotomy + cardio-pulmonary bypass – anatomic re-positioning
• Webs – surgery for thick webs refractory to endoscopic Rx
  • Transcervical or transthoracic approach to oesophagus
  • Longitudinal myotomy & circumferential excision of web, circumferential re-approximation of mucosa with interrupted absorbable sutures followed by longitudinal closure of muscle
• Anti-reflux procedures ± Collis gastroplasty (as oesophageal shortening often present) –
  • Creating a gastric tube & bringing it up into the thorax
• Resection and reconstruction- delay for at least 6 months.
  • Stomach pull-up, versus jejunal loop interposition, versus long-segment colon interposition graft.
  • Need to resect oesophagus/stomach – 1000 x increased risk of cancer