It is my pleasure to introduce our next speaker, Dr. Dana Earley. She is a professor of medicine in the Department of Medicine and Division of Gastroenterology at Washington University in St. Louis. She is the Medical Director of Endoscopy at Barnes-Jewish Hospital, and she has served on numerous ASG committees, like Health and Public Policy, Standards of Practice, and Research, and she is the current chair of the ACG Board of Governors. She will be talking to us about the diagnostic approach to strictures, and then we'll also go over esophageal strictures and management. Dana, thank you so much. Great. Good morning, everybody. Looks like I'm in control of my slides. I wanted to thank Prateek and Vani and Marilyn for inviting me to talk this morning, and you know, there's a fair amount of overlap between my two talks, but I kind of tried to keep them separate as best as I can to sort of stick to the title. So here's just a list of types of esophageal strictures, and this isn't an all-inclusive list, but I tried to include, you know, the most common things that you would experience in terms of, you know, your clinical practice. So I think the top three are probably the most common esophageal strictures that we do encounter, you know, erosive esophagitis and peptic strictures, just because gastroesophageal reflux disease is so prevalent these days, particularly, you know, in the United States, and so these are common causes of strictures and are generally treated very similarly. Eosinophilic esophagitis is obviously a cause of esophageal stricture, and we're going to hear about this in the next session in terms of diagnosis and management, but need to keep that high in your differential. Inflammation-induced esophagitis and strictures is something you can see in a patient that has the appropriate history, so we'll talk about history in a bit, but this is where that really helps you. Malignant strictures, you know, can occur, and you generally get a fairly good feel that this might be the cause based on the patient's symptom and course of their dysphagia. Causing injections are uncommon but do occur, and you can elicit that during the history. And then post-surgical or anastomotic strictures, you know, obviously do occur and can be managed endoscopically. So I think history is very important if you want to narrow down what you think the cause of the dysphagia and possible stricture is, so, you know, it's important to gather this information before you do the endoscopy because you want to have a good idea of what you're dealing with, or obviously if you see the patient in the office first for dysphagia, these are some of the things that you want to ask about so you know which direction you're heading in terms of evaluating their dysphagia and possible stricture. So again, you know, heartburn is very common, so we want to elicit a history of heartburn in terms of the frequency, the severity, and the chronicity of it, and that will help you decide if you think erosive esophagitis or peptic stricture is high on your list. And then certainly if you gather a history of a very progressive nature of dysphagia and associated weight loss, you're certainly going to be concerned about esophageal cancer. If you gather a history of intermittent dysphagia, you might be thinking more of a ring or a web or eosinophilic esophagitis, so you want to keep that in mind as you're doing evaluation. Certainly webs, I haven't seen those very often, but you want to be fairly careful when you're intubating the esophagus if you think there might be a web. In terms of the progressive nature of symptoms, this is going to generally lead you to think of a peptic stricture or a cancer. In patients that give a history of a food impaction, this could really be due to any number of causes of strictures, but we tend to see that most commonly in patients with EOE or a peptic stricture, a ring, or a cancer. If they've had a food impaction and they've had a disimpaction with endoscopy, you're generally going to know if they have a cancer, but you're not always going to be able to know if they've had that endoscopy in the emergency room, whether there were any features of EOE, peptic stricture, or a ring, just depending on the setting and how that procedure went. Prior surgery, obviously you're going to elicit that information from the history. I tend to like to wait at least a month after surgery to dilate an anastomotic stricture. I think if your surgeons are really pushing you, I suppose it's fine to go ahead and evaluate that patient, but I would be very cautious about dilating an anastomotic stricture too soon after a surgery. Prior radiation, again, that's obviously going to come from your history, and radiation-induced strictures can be particularly problematic, but obviously those that can occur after radiation. And notably, sometimes the dysphagia develops during the radiation course, or it can develop after the radiation course has completed, and it can also develop sometime after the radiation course is completed. As you know, radiation injury to the luminal GI tract has an extremely variable course, so even if the radiation is somewhat remote, that doesn't rule out the fact the patient may have a radiation-induced stricture. Again, you can get a history of prior caustic injections, ingestion. You probably want to specifically ask about that because it might not be something that a patient would necessarily know about unless it was a fairly significant event. And then you also want to ask about the warning signs such as weight loss, hematemesis, or progressive nature, because you'll certainly be thinking about esophageal cancer high on your list in those situations. In terms of evaluation, you know the saying, if you go to a barber, you're going to get a haircut. So if you have dysphagia and you see a gastroenterologist, you're going to get an endoscopy. But I think there is a role for non-invasive imaging as well. So the two main ways to evaluate a patient with a potential esophageal stricture or even a known esophageal stricture would include a barium esophagram. This is non-invasive, and so it's very safe. Generally it's performed with liquid barium, although at our center, we have to specifically request if we want a barium tablet to be administered, but that's a really good way to tease out an esophageal ring, for example, that might not be identified with liquid barium. So barium esophagram can actually be fairly good for more subtle findings and sometimes even better than endoscopy for rings. And then if you suspect or know that you're dealing with a complex stricture or possibly a proximal stricture, it really can be useful for creating sort of a map of the esophagus so that when you do perform your endoscopy, you know what you're going to be encountering and where you're going to be encountering the stricture. So endoscopy, you know, obviously is my favorite mode to evaluate an esophageal stricture or a patient with dysphagia, and generally all cases of dysphagia are going to lead to endoscopy unless there's an obvious motility issue or oropharyngeal dysphagia nature to the symptoms. But even in those settings, oftentimes endoscopy really is necessary. And so the obvious advantage is that it allows for diagnosis, so you can see what the cause of the stricture is, you can take biopsies if that's relevant, and then you can manage it with dilation and all in the same setting. So just a couple of pictures for you. On the left is a barium esophagram of a patient with dysphagia. And you can see at the top, the esophagus is dilated here. And then you see an asymmetric stricture with a relatively normal esophagus distal to this. And so on endoscopy, this was noted to be an esophageal web in the proximal esophagus. And you can also see there's actually a small esophageal diverticulum here. So this is what we call a Pohl's diverticulum. So most likely it's due to the fact that there's some pressure in the upper esophagus from the narrowing due to the web. And I didn't see this in the barium esophagram, it wasn't called out, but this is really important to know because you want to be particularly careful when you're intubating the esophagus in the setting of an esophageal diverticulum. Also, if you're dilating this web, you want to be very cautious of this diverticulum. So another barium esophagram showing the primary portion of the esophagus is normal. And then when you get to the GE junction, you're encountering symmetrical narrowing with a hiatal hernia distal to it. And then on endoscopy, this is a very classic appearance of a ring. A ring is a mucosal only, and generally they're at the EG junction. And so they have squamous mucosa on one side and the columnar mucosa on the other side. There's a metric, the narrowing associated with them can be variable. And you may see these actually in asymptomatic patients or you may be doing endoscopy for another reason and see these. When I do see these in a patient that doesn't give a history of dysphagia, I generally don't dilate unless it is particularly narrow. This ring in particular, I think I would dilate because I would expect that this would be symptomatic. But you don't always have to dilate rings if they're asymmetric or the patient doesn't give any history of dysphagia. So I have a couple of cases. So this is an 80 year old female that I ended up seeing, but she messaged her PCP through our electronic chart and said that she had a dinner one night, she started choking on her food. And, you know, choking to a patient means that they have trouble swallowing the food or it may mean that they start coughing. And this is really a history that you need to elaborate on, because if they're actually coughing when they're eating, that makes you consider the fact they may have oropharyngeal dysphagia. But she said she had to run to the bathroom and throw up her food. And then she had progressive symptoms. So she had a solid food dysphagia. And then she indicates that she has progressive dysphagia because now she's having trouble swallowing not only food, but some of her medications. When I met this patient, she didn't have any history of heartburn. So I really wasn't thinking of a peptic stricture or esophagitis. I was concerned about esophageal cancer. I did think she might have a ring. I thought that was somewhat unusual to present in an 80 year old. I also thought EOE would be fairly unusual to present in an 80 year old. So I wasn't entirely clear what this patient had as the cause of her stricture. So her PCP decided to order a barium swallow, which is not unreasonable to do in an 80 year old. And as you can see, the barium column is normal until you get to the junction. And there's a fairly significant narrowing here. And they did give this patient a barium tablet, which didn't pass. And so this patient presented for endoscopy. And so, as you can see here, she has grade D esophagitis. So she, in fact, has fairly significant gastroesophageal reflux disease. I elected not to dilate her on the initial endoscopy, although as I traversed her, I was able to traverse the stricture with the endoscope and caused a slight mucosal tear. So she essentially had a mild dilation just with the endoscopy itself. And so I elected to treat her medically and bring her back and reevaluate her esophagus. Oops, it's a different case. This is a gentleman in his late 50s who had BE with nodularity and ended up having an EUS and EMR of a nodule that turned out to be a T1SM lesion. And so we typically treat these as chemo radiotherapy. So he underwent that. And then he returned after he completed his chemo radiotherapy, not too long after he had completed it with dysphagia. And so on the upper right-hand corner, you can see what I would consider. This could look like a bad peptic stricture and esophagitis, but it was very suspicious for a radiation stricture just based on his history. He did have residual BE after he underwent the chemo radiotherapy with low-grade dysplasia. So, again, this is a stricture I wasn't particularly keen on dilating right then. But I did get a modest dilation just with passing the endoscope. You can see the blood there. And so this is a patient that would require some follow-up. So after the dilation, actually, his esophageal lumen looked much better. As I mentioned, he had residual BE, and he had low-grade dysplasia. So I thought it would be best to treat this. And in hindsight, maybe that wasn't the best thing to do, but I probably would do it again. But then he developed a really significant stricture that really has the features of a radiation stricture. Why it kind of improved and then reoccurred in this appearance is not really clear to me. But he has, you know, deep ulceration here. It may not show up as well in this picture, but this patient does have deep ulceration that encompasses over half of the circumference of his esophagus. And you'll note when you see patients with radiation strictures, not so much in this patient because he had a distal esophageal cancer, and that's where his radiation was targeted. But let's say you have a patient with lung mass, and they had radiation or maybe breast cancer. You tend to note that the esophagus is really normal. Up until you reach the field of radiation, then you see these exudates and ulcerations, friability, and then the esophagus is normal below it. So it really, in some instances, can be fairly stark, the difference between the esophagus that was not exposed to the radiation and the esophagus that was. And this is kind of a hallmark feature, I think, of radiation esophagitis. Just more pictures of that same patient. And then I had one more case of a 39-year-old. She'd had several years of intermittent solid food dysphagia and two episodes of food impaction. She is otherwise normal, didn't report any heartburn. So I'm thinking here, does she have a ring? Does she have a web? Does she have EOE? You know, she doesn't have any history of heartburn, which doesn't rule out a peptic stricture, but I think makes it less likely. She had no contraindications to having endoscopy, so obviously went directly to endoscopy. And hopefully this picture shows up well, but you can see that she has, Dr. Hirano will go over the features, but she has these linear furrows, she has longitudinal rings. And so this is a fairly classic picture of eosinophilic esophagitis in this relatively young patient. So just some take-home points in terms of diagnosis of esophageal strictures. I think symptom characteristics and history are really key elements to at least narrowing down your differential in terms of the etiology of esophageal strictures in patients with dysphagia. And it's really, you know, mandatory to image the esophagus. Certainly radiography is fine. Performing a barium swallow is appropriate. I would say that if I'm going to order a barium swallow, I'm going to put on my request that if no etiology is identified with liquid barium to administer a barium tablet, since this will help you identify more subtle findings such as a dysesophageal ring that might not be evident on with liquid barium or even at a time of endoscopy, but would require dilation. But ultimately, endoscopy is needed in nearly all cases to diagnose esophageal strictures and then to treat them when appropriate. And it's certainly the preferred method.

esophageal strictures

diagnostic approach

dysphagia

barium esophagram

endoscopy