Oesophageal Strictures Webs and Rings

Narrowing or occlussion of the oesophagus can be from within or without. It is imperative to be aware of the warning signs that may suggest malignancy and to make urgent referral where necessary. In other cases work-up is appropriate to define the lesion and to decide appropriate management. In addition to webs, rings and strictures there are abnormalities of peristalsis such as achalasia of the cardia that may cause dysphagia.

Related articles include:

• Gastro-oesophageal reflux disease
• Carcinoma of oesophagus
• Paterson-Brown-Kelly syndrome (Plummer-Vinson syndrome)

Most oesophageal narrowings will present with dysphagia or symptoms suggestive of heartburn or indigestion, although some are found incidentally at endoscopy in patients with pathology elsewhere in the upper GI tract, such as duodenal ulcer.

History

• Presenting features include heartburn, dysphagia, impaction of food, weight loss and chest pain.
• Dysphagia progresses from hard food such as meat to sloppy food like porridge to liquids.
• The degree of dysphagia is more related to the degree of oesophagitis than the extent of narrowing and correlation is rather poor.¹
• Persistent cough and wheeze due to aspiration of food or acid are less common presentations.
• Ask about progression of symptoms and the time span.
• There may be a history of gastro-oesophageal reflux disease (GORD). This does not necessarily indicate a benign peptic structure as Barrett's oesophagus may progress to adenocarcinoma.

Examination

Assess the nutritional status of the patient, examine the abdomen noting any tenderness or organomegaly.

• FBC may show evidence of chronic blood loss with iron deficiency anaemia, non-anaemic iron deficiency or even poor nutrition with iron and folate deficiency.
• Abnormal LFTs suggest metastasis to the liver.
• Chest x-ray may show a mass in the chest impinging on the oesophagus. The gross dilatation of achalasia is characteristic. Lung disease due to inhalation may be seen.
• Endoscopy and barium swallow may both delinate the lesion but both have advantages and disadvantages.
  • Endoscopy allows the lesion to be biopsied but it is also very easy to perforate the oesophagus, especially if the lesion is malignant.
  • A barium swallow is usually required to clarify the nature and length of stricture before attempting to pass the scope through the stricture. It may be appropriate to arrange an urgent barium swallow before endoscopy where dysphagia and weight loss are prominent.
• CT or endoscopic ultrasound are good ways to stage tumours and detect metastases.

Causes

• Oesophageal Strictures may be benign or malignant.
  • Benign oesophageal strictures are usually the result of scarring from acid reflux in severe and persistent gastro-oesophageal reflux disease. This represents about 70 to 80% of all oesophageal strictures and is 2 or 3 times more common in men. It may also follow ingestion of corrosives. About 25% of patients with peptic stricture give no history of heartburn.
  • Postoperative strictures represent about 10% and corrosives account for less than 5%. Drugs that can cause strictures include alendronate, iron, NSAIDs, and potassium chloride. NSAIDs should be prescribed with caution in patients with known GORD.²
  • Malignant oesophageal strictures usually result from carcinoma of oesophagus but may ascend from carcinoma of stomach.
• Oesophageal webs are often about 2 or 3 mm wide. It is a smooth extension of normal oesophageal tissue containing just mucosa and submucosa and can occur anywhere along the oesophagus but classically at the anterior postcricoid area of the upper oesophagus. This is the Paterson-Brown-Kelly syndrome, also known as Plummer-Vinson syndrome in the USA. It is associated with iron deficiency. There may be koilonychia (spoon nails), cheilosis and glossitis. Webs are more frequent in women and this may be related to propensity for iron deficiency. Most upper oesophageal webs are not associated with Paterson-Brown-Kelly syndrome.³
• Oesophageal rings are concentric, smooth, thin extension of normal oesophageal tissue that are usually 3 to 5mm thick. They consist of mucosa, submucosa and muscle. They may be an incidental finding at barium studies or endoscopy. Incidence is unknown as most are asymptomatic. There is no sex difference in the incidence of rings except that multiple rings are usually found in young men. Rings are classified as A, B and C.
  • A is uncommon and is a muscular ring several centimetres proximal to the squamocolumnar junction. It may be an inconstant finding on barium swallow and there is some debate as to whether it really is an anatomical entity.
  • B ring or Schatzki ring is really a web as it involves only mucosa and submucosa. It tends to mark the proximal part of a hiatus hernia and usually present in a patient over 50 whose main complaint is intermittent dysphagia to solid food spanning months or years and it is non progressive.
  • C ring is a rare x-ray finding of indentation caused by the diaphragmatic crura. It is rarely causes symptoms.
• Extrinsic lesions may compress the oesophagus from outside. It is usually a thoracic aortic aneurysm or carcinoma of lung. Other possible causes are from enlarged hilar lymph nodes as in bilateral hilar lymphadenopathy of sarcoidosis, tuberculosis or lymphoma.

Eosinophilic oeshophagitis is a recently described condition that is due to allergy. The symptoms resemble GORD and even barium swallow may susggest that diagnosis.⁴ Correct diagnosis is important as the treatment is different.

Dysphagia is one of the features that may indicate malignancy, and demands urgent referral⁵
Other worrying features include:⁶

• Rapidly progressive symptoms
• Weight loss
• Iron deficiency anaemia
• Dysphagia

Failure of peristalsis occurs in achalasia and may present with dysphagia.

• Benign strictures or rings are managed by oesophageal dilation at endoscopy. This may be achieved under light sedation. Usually an inflatable balloon or bougie is passed down a guidewire. Long term use of PPIs seems beneficial in reducing the frequency of repeated dilatations.⁷
• Those who need frequent dilatation initially are likely to continue with this pattern. They are more likely to suffer weight loss and less likely to suffer heartburn.⁷ Poor results will require consultation with a surgeon.
• Malignant strictures will require either surgical excision (oesophagectomy) or palliative management with a oesophageal stent (Atkinson tube or similar).
• In Paterson-Brown-Kelly syndrome, merely correcting iron deficiency may reverse symptoms.⁸
• Eosinophilic oesophagitis will respond to topical steroids.⁹

• Aspiration pneumonitis
• Complete obstruction of food can occur. This requires removal at endoscopy. Barium studies must not be performed if this is suspected.
• Severe dysphagia can lead to malnutrition.
• Dilatation can cause bleeding or perforation although spontaneous perforation of webs or rings is rare.
• Paterson-Brown-Kelly syndrome is associated with risk of malignant change but it seems that correction of the iron deficiency reverses both the disease and the risk. In Northern Sweden, where the risk in women has been traditionally very high, correction of deficiency has had a beneficial effect on both Paterson-Brown-Kelly syndrome and post-cricoid carcinoma.¹⁰

With benign causes:

• Mild symptoms respond to dietary modifications and change in eating habits.
• Moderate symptoms respond well to dilatation but it may need repeating.
• Surgery is rarely needed.
• There is a potential progression from normal oesophagus to lower oesophageal ring to oesophageal stricture that occurs in association with reflux oesophagitis.¹¹ Anti-reflux therapy may slow or prevent progression.¹²

For malignant causes, see the article on carcinoma of oesophagus.