Esophageal Strictures

Esophageal Strictures are either benign or malignant, and the distinction is critical. Benign strictures are either congenital or acquired.

A. Congenital webs

Congenital webs are the only true congenital esophageal strictures. They represent a failure of appropriate canalization of the esophagus during development and can occur at any level. An imperforate web must be distinguished from a tracheoesophageal fistula, although a perforate web may not produce symptoms until feedings become solid.

B. Acquired strictures

Esophageal rings or webs occur at all levels in relation to the etiology of the webbing process. An example is Schatzki ring, which occurs in the lower esophagus at the junction of the squamous and columnar epithelium. A hiatal hernia is always present, and the etiology is presumed to be GER. Esophagitis is rarely present. Treatment generally consists of medical management of reflux with periodic dilation for symptoms of dysphagia.

Strictures of the esophagus can result from any esophageal injury, including chronic reflux, previous perforation, infection, or inflammation.

C. Symptoms

Symptoms associated with a stricture consist of progressive dysphagia to solid food and usually begin when the esophageal lumen narrows beyond 12 mm.

D. Evaluation and treatment

Evaluation and treatment of a stricture begins with the categorical exclusion of malignancy. The diagnosis usually is based on a barium swallow. Esophagoscopy is essential to assess the location, length, size, and distensibility of the stricture and to obtain appropriate biopsies or brushings. Because a peptic stricture secondary to reflux always occurs at the squamocolumnar junction, biopsy of the esophageal mucosa below a high stricture should demonstrate columnar mucosa. If squamous mucosa is found, the presumptive diagnosis of a malignant obstruction should be made, although strictures due to Crohn disease, previous lye ingestion, or monilial esophagitis are among alternative diagnoses. Most strictures are amenable to dilation, and this relieves the symptoms. Attention is then directed at correcting the underlying etiology. Resection can be required for recurrent or persistent strictures or if malignancy cannot be ruled out.