Diagnosis Of Esophageal Stricture Research Articles

Caustic esophageal stricture from diagnosis untill cure

Background: The diagnosis of esophageal stricture after caustic ingestion is based on clinical symptoms of dysphagia, regurgitation and chocking that is evident initially in the acute stage. These symptoms may ameliorate by time or proceed to evident stricture due to fibrosis. This will need either dye esophagogram or Esophagoscopy which is better to be done not before the lapse of at least 6 weeks from injury. Esophageal dilatation using wire-guided dilators is the cornerstone of treatment. The frequency of dilatation is based on recurrence of dysphagia and in multiple strictures, repeated sessions with multi-level injection of steroids and graded dilatation is needed. Failure of dilatation or occurrence of complications may necessitate esophageal replacement and usually we prefer the transverse colon based on the left colic vessels in retrosternal position to treat the condition. We aimed to review the management of caustic esophageal strictures based on what is known and adding our experience in this aspect. Methods: We reviewed the articles discussing management of caustic esophageal strictures in the last twenty years. We added our experience of more than forty years managing an average of thirty new cases every year. Results: Management of caustic esophageal strictures has changed in the last years. Advanced endoscopic techniques of dilatation reduced the need for esophageal replacement. Conclusions: Caustic esophageal strictures could be managed successfully with advanced techniques of endoscopic dilatation. Keywords: Caustic stricture; esophageal dilatation; esophagoscopy; esophageal replacement

The Safety and Feasibility of Transesophageal Echocardiography in Patients With Esophageal Stricture

Expert guidelines consistently list esophageal stricture (ES) as a contraindication to the performance of transesophageal echocardiography (TEE), although anecdotally the authors are aware of patients with ES undergoing TEE without apparent complication. Therefore the authors sought to determine the outcomes of patients with ES who had undergone TEE at their institution. Single-center, retrospective review. Academic medical center (clinic and affiliated hospital). Patients with documented ES who also underwent TEE. None. In a 10-year period, 1,083 TEE reports were generated for 823 patients who had a diagnosis of ES. One case of esophageal perforation occurred (1/1,083 examination reports [0.09%]) in an 85-year-old male with gastroesophageal reflux disease-related ES who had undergone esophageal dilation the same day as the TEE. In 17.2% of the TEE reports reviewed, changes to the conduct of the examination occurred, such as use of a pediatric probe or avoidance of transgastric imaging. In 8% of reviewed examinations, procedural difficulty was recorded. Patients with nonmalignant ES commonly present for TEE (>100 per year, on average, at the authors' institution). Severe TEE-related esophageal injury rarely occurred in patients with ES. However, changes to the conduct of the TEE examination and procedural difficulty were not infrequent in this group. Clinicians contemplating TEE in patients with ES should prepare for the possibility of altered examination conduct and possible procedural difficulty.

Clinical Quiz

A 13-month-old white female presented to the emergency department with a two-month history of intermittent cough and spitting up. The cough was non-productive and the parents did not associate it with feeding or episodes of regurgitation. There was no frank vomiting, fever, rhinorrhea, or weight loss; however, the child was below the fifth percentile for weight. Her length was at the twenty-fifth percentile. The child had begun refusing baby food and solids with the onset of symptoms. Her diet consisted primarily of milk and juices. Her medical history was negative for reactive airway disease and recurrent infections, including pneumonia, otitis media, and diarrhea. The patient was treated for gastroesophageal reflux with an H-2 blocker and a prokinetic medication until she was 9 months old when she `outgrew` her spitting up. There is no history of hospitalization or surgery. Family history is negative for asthma, cystic fibrosis, and α-1-antitrypsin deficiency. Physical examination revealed a pale, thin, white female in no respiratory distress. Lung and abdominal exams were normal. Heart exam uncovered a I-II/VI systolic murmur along the lower left sternal border. There was no digital clubbing. Rectal exam revealed soft, brown, occult blood-positive stool. Chest radiographs were obtained (Fig. 1). Other evaluation included electrolytes and liver panel, which were unremarkable. A CBC showed a microcytic anemia, with a hemoglobin of 7.3 g/dl and a mean corpuscular volume of 68 fl.FIG. 1.What is the next step in the treatment of this infant? A. Upper gastrointestinal endoscopy B. 2-D echocardiogram C. Chest CT D. Contrast radiography of the esophagus E. Surgery consult Answer: D, because a dilated proximal esophagus is seen on both the AP and lateral views of the chest. A barium esophagram via a nasogastric tube showed a stricture in the lower esophagus (Fig. 2). Further questioning did not uncover a history of caustic ingestion. The esophageal lumen was markedly stenotic at endoscopy (Fig. 3). A biopsy of the esophagus just proximal to the stricture showed changes consistent with reflux esophagitis, supporting a diagnosis of peptic stricture. The patient was started on a proton pump inhibitor and an age-appropriate complete formula. Dilation was initiated with over-the-wire dilators.FIG. 2.FIG. 3.DISCUSSION Gastroesophageal reflux (GER) is a common finding in infants and is usually viewed as a benign condition; yet, significant complications can arise from prolonged, untreated GER, including esophageal strictures. It has been estimated that 80% of strictures are due to untreated esophagitis (1). Children may develop them in relatively short fashion, in contrast to the prolonged amount of time it takes for adults to develop peptic esophageal strictures (2). Disorders that predispose to the development of esophageal strictures include dysmotility disorders, hiatal hernia, scleroderma, Zollinger-Ellison syndrome, chronic nasogastric tube placement, caustic ingestion, and NSAID ingestion (1). While rare in children, there is an association between stricture formation and the development of Barrett's esophagus. The differential diagnosis for esophageal stricture includes vascular rings, achalasia, Schatzki ring, and esophageal foreign body. Dysphagia is the most common presenting complaint; however, some patients, particularly children, have no complaints. Patients may report a prior history of GER that has resolved, indicating that stricture formation is preventing the reflux of gastric contents. Atypical symptoms of an esophageal stricture include chronic cough and reactive airway disease related to aspiration or vagally mediated bronchospasm. Weight loss is uncommon and, when present, should prompt the physician to search for other contributing causes. The diagnosis of esophageal strictures is best made with contrast radiography of the esophagus. Manometry is beneficial when a diagnosis of achalasia is being entertained. Upper gastrointestinal endoscopy is essential for delineating the cause of the stricture and for treatment. Treatment of strictures begins with patient education and lifestyle modification. Patients should be instructed on safe foods and healthy eating habits to reduce the risk of food impaction and the potential for aspiration. Acid suppression is important to lessen ongoing injurious acid reflux, and is best accomplished with a proton-pump inhibitor. Esophageal dilation is often required to relieve dysphagia. Initial dilation using an over-the-wire technique is preferable to blind dilation with rigid dilators. Balloon dilation may be considered since this lessens the risk of esophageal perforation as the pressure is applied in an even radial fashion. Surgical intervention is indicated for recurrent strictures and failure of medical therapy.

The role of endoscopic ultrasonography in the diagnosis and staging of esophageal stenoses

Endoscopic ultrasonography (EUS) is a well-established method for the evaluation and staging of patients with esophageal cancer. It allows accurate tumor staging and the detection of local and distant lymph node metastasis. With the advent of the curvilinear echoendoscope, fine needle aspiration biopsy of perigastrointestinal tract targets such as lymph nodes and liver metastasis became routine and allowed the documentation of these targets' malignant involvement before neoadjuvant therapy. In addition, fine needle injection therapy can be delivered accurately. In endoscopy-negative patients whose clinical presentation is compatible with esophageal cancer, EUS can detect malignancy where other conventional methods have failed to identify a diagnosis. This report reviews the role of EUS in staging esophageal malignancies as well as in the diagnosis of esophageal strictures of unknown etiology. We will describe the currently available equipment, techniques currently used to stage esophageal cancer, and the techniques used to perform fine needle aspiration biopsy and fine needle injection therapy.

Esophageal stricture secondary to Stevens-Johnson syndrome

We report a 7-year-old male with ampicillin-induced Stevens-Johnson syndrome with subsequent extensive skin, conjunctival, oropharyngeal, and laryngeal involvement. Over the next 5 months, he developed complete blindness and dysphagia. A barium swallow revealed absence of both right and left pyriform sinus, and a stricture involving the entire esophagus. Retrograde dilatations, complicated by malignant hyperthermia, have subsequently allowed for the difficult progression from an eight to a 40 French bougie. Eighteen months since the diagnosis of esophageal stricture, he has a normal appearing esophagus and is swallowing without difficulty.

ROENTGEN DIAGNOSIS OF GASTRIC SYPHILIS

In June, 1913, I made my first roentgenologic diagnosis of gastric syphilis. The diagnosis was made prior to the examination of the blood, which later was reported as giving a four plus Wassermann reaction. The diagnosis was confirmed also by operation, at which time a gastro-enterostomy was performed by Dr. W. A. Downes, who used the proximal portion of a stomach showing the dumb-bell type of hour-glass deformity. The patient, at that time a girl, aged 14, was referred to me for roentgen examination from the outpatient department of St. Luke's Hospital, New York, with the clinical diagnosis of esophageal stricture. The case was evidently one of congenital syphilis (fig. 1 A ). I have reexamined this patient several times. The last examination, made June 12, 1930, seventeen years after gastro-enterostomy, shows that the stomach empties readily through the new opening. Some dilatation of the esophagus still remains as noted at