Radiographic Pictorial Review of Esophageal strictures

1. Dr. Naveed AshrafRadiologic Pictorial Review
Esophageal Strictures
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2. Dr. Naveed AshrafRadiologic Pictorial Review
TEACHING POINTS
Peptic stricture
• A peptic stricture is secondary to chronic reflux.
• Peptic strictures are located distally, usually just above the GE
junction.
• A peptic stricture may be focal or involve a longer segment of
esophagus.
• Fibrosis can cause esophageal shortening, leading to a hiatal
hernia as the stomach is pulled into the thorax.
Barrett esophagus stricture
• A Barrett stricture typically occurs in the mid-esophagus, above
the metaplastic adenomatous transition. Barrett strictures occur
higher than peptic strictures because adenomatous tissue is acid-
resistant and therefore unaffected by gastric secretions.
Malignant stricture (due to esophageal carcinoma)
• Key imaging finding is shouldered margins, which suggests
circumferential luminal narrowing by a mass.
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3. Dr. Naveed AshrafRadiologic Pictorial Review
TEACHING POINTS
Caustic stricture/nasogastric (NG) tube stricture
• Both caustic strictures and strictures secondary to nasogastric
tube placement are typically long, smooth, and narrow.
• Strictures develop 1–3 months after the caustic ingestion or NG
tube placement.
• Caustic strictures are associated with an increased risk of cancer,
with a long lag time of up to 20 years after the initial insult. Caustic
strictures are usually longer than peptic strictures.
Radiation stricture
• Radiation strictures are long, smooth and narrow, similar to
caustic strictures. However, in contrast to strictures from an NG
tube, caustic ingestion, and reflux, radiation strictures usually
spare the GE junction.
• It generally requires more than 50 Gy of radiation to cause an
esophageal stricture.
• Acute radiation esophagitis occurs 1–4 weeks after radiation
therapy. Radiation strictures develop later, occurring 4–8 months
after radiation.
Extrinsic compression from mediastinal adenopathy
• Cross-sectional imaging would best evaluate if extrinsic
compression is suspected.
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4. Dr. Naveed AshrafRadiologic Pictorial Review
Peptic stricture with esophageal intramural pseudodiverticula. Double-
contrast esophagogram shows a smooth, tapered area of concentric
narrowing in the distal esophagus (large arrow) above a hiatal hernia. This
is the classic appearance of a peptic stricture. Note also the tiny
esophageal intramural pseudodiverticula in the region of the stricture
(small arrows). Some of the pseudodiverticula seem to be “floating”
outside the wall of the esophagus without direct communication with the
lumen, a characteristic radiographic feature of these structures.
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5. Dr. Naveed AshrafRadiologic Pictorial Review
Peptic stricture. Doublecontrast esophagogram shows an eccentric area of
narrowing in the distal esophagus (arrow), a finding that resulted from
asymmetric scarring from reflux esophagitis.
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6. Dr. Naveed AshrafRadiologic Pictorial Review
Peptic stricture with sacculations. Double-contrast esophagogram shows
an eccentric area of narrowing in the distal esophagus (black arrow) above
a hiatal hernia. Note the associated sacculations (white arrows) that
resulted from outward ballooning of the esophageal wall between areas of
fibrosis.
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7. Dr. Naveed AshrafRadiologic Pictorial Review
Peptic stricture with fixed transverse folds. Double-contrast esophagogram
shows a mild peptic stricture in the distal esophagus (white arrow) with
barium collections between fixed transverse folds (black arrows), findings
that produce a characteristic “stepladder” appearance. Note that the folds
are wider than the delicate transverse striations in feline esophagus and
do not extend more than halfway across the esophagus.
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8. Dr. Naveed AshrafRadiologic Pictorial Review
Ringlike peptic stricture. Double-contrast esophagogram shows an area of
ringlike narrowing in the distal esophagus (arrows) above a hiatal hernia.
Note the resemblance to a Schatzki ring. However, this ringlike stricture is
more asymmetric and has more tapered borders and a greater length than
do most Schatzki rings.
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9. Dr. Naveed AshrafRadiologic Pictorial Review
Schatzki ring. Prone single-contrast esophagogram shows a classic Schatzki
ring (arrows), which appears as a smooth, symmetric, ringlike constriction
at the gastroesophageal junction above a hiatal hernia. Note that the ring
has a length of only 2 mm and has more abrupt borders than does a
ringlike peptic stricture.
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10. Dr. Naveed AshrafRadiologic Pictorial Review
Infiltrating esophageal carcinoma. Double-contrast esophagogram shows a
malignant stricture with the typical features: a markedly irregular contour
and abrupt, shelflike proximal and distal margins (arrows).
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11. Dr. Naveed AshrafRadiologic Pictorial Review
Scleroderma with a peptic stricture. Double-contrast esophagogram shows
a relatively long segment of tapered narrowing in the distal esophagus
(arrows) that resulted from marked peptic scarring in a patient with
esophageal involvement by scleroderma.
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12. Dr. Naveed AshrafRadiologic Pictorial Review
Nasogastric intubation stricture. Prone single-contrast esophagogram
shows a relatively long segment of narrowing in the distal esophagus
(arrows). This stricture developed 3 months after prolonged nasogastric
intubation.
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13. Dr. Naveed AshrafRadiologic Pictorial Review
Barrett esophagus with a midesophageal stricture and a reticular pattern.
Double-contrast esophagogram shows a focal area of mild narrowing in
the midesophagus (black arrow). Note also the distinctive reticular pattern
that extends distally a considerable distance from the stricture
(approximately to the level indicated by the white arrow). This reticular
pattern is thought to result from intestinal metaplasia in Barrett mucosa.
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14. Dr. Naveed AshrafRadiologic Pictorial Review
Barrett esophagus with a midesophageal stricture. Double-contrast
esophagogram shows a relatively long segment of tapered narrowing in
the midesophagus (arrows). A hiatal hernia and gastroesophageal reflux
were seen at fluoroscopy.
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15. Dr. Naveed AshrafRadiologic Pictorial Review
Radiation stricture. Double-contrast esophagogram shows a smooth,
tapered segment of concentric narrowing in the midesophagus (arrows).
The stricture was caused by prior mediastinal irradiation.
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16. Dr. Naveed AshrafRadiologic Pictorial Review
Caustic stricture. Double-contrast esophagogram shows a long stricture
involving most of the thoracic esophagus. The stricture resulted from
ingestion of a caustic substance many years earlier.
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17. Dr. Naveed AshrafRadiologic Pictorial Review
Drug-induced stricture in a patient who developed dysphagia 6 months
after taking potassium chloride for hypokalemia. Double-contrast
esophagogram shows a slightly asymmetric focal area of narrowing in the
upper thoracic esophagus (arrow) above the level of the aortic arch.
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18. Dr. Naveed AshrafRadiologic Pictorial Review
Congenital esophageal stenosis in a young man with longstanding
dysphagia and occasional superimposed food impactions. Doublecontrast
esophagogram shows an area of mild narrowing in the midesophagus with
distinctive ringlike indentations (“ringed esophagus”) (arrows) in the
region of the stricture. Endoscopic findings confirmed the presence of a
mild stricture in the midesophagus with indentations that resembled
tracheal rings.
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19. Dr. Naveed AshrafRadiologic Pictorial Review
Esophageal intramural
pseudodiverticulosis. Double-
contrast esophagogram shows a
moderately long stricture in the
upper thoracic esophagus
(straight solid arrows). Note the
tiny esophageal intramural
pseudodiverticula (curved solid
arrows) at and below the level of
the stricture. Note also the
intramural tracking of barium
between adjacent
pseudodiverticula (open arrows).
Despite the dramatic radiographic
findings in such cases, a localized
cluster of pseudodiverticula in the
distal esophagus in the region of a
peptic stricture is actually more
common.
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20. Dr. Naveed AshrafRadiologic Pictorial Review
Benign mucous membrane pemphigoid. Single-contrast esophagogram
shows a focal stricture in the upper esophagus (arrow) near the thoracic
inlet. The stricture resulted from esophageal involvement by benign
mucous membrane pemphigoid. Other skin diseases such as epidermolysis
bullosa dystrophica may produce similar strictures.
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21. Dr. Naveed AshrafRadiologic Pictorial Review
Esophageal stricture caused by endoscopic sclerotherapy. Single-contrast
esophagogram shows a long, irregular stricture in the distal esophagus
(straight white arrows) that resulted from scarring caused by prior
endoscopic sclerotherapy for esophageal varices. Note also the flat ulcer in
the region of the stricture (curved white arrow). Black arrows indicate a
transjugular intrahepatic portosystemic shunt.
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22. Dr. Naveed AshrafRadiologic Pictorial Review
Glutaraldehyde induced stricture in a patient who developed dysphagia
several months after undergoing endoscopy. Double-contrast
esophagogram shows a long stricture that involves the middle and distal
esophagus (arrows). There were no other predisposing factors for the
development of this stricture, which was presumed to be caused by
toxicity from residual glutaraldehyde at endoscopy.
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23. Dr. Naveed AshrafRadiologic Pictorial Review
67-year-old woman with peptic stricture that was judged to be benign by
observers. A, Left posterior oblique double-contrast esophagogram
obtained with patient upright shows benign-appearing stricture (arrow) in
distal esophagus. Note that stricture has smooth contour and tapered
borders. B, Right anterior oblique single-contrast esophagogram obtained
with patient prone shows smooth, tapered stricture (arrow) in distal
esophagus above hiatal hernia. Endoscopy (not shown) revealed peptic
stricture, and endoscopic biopsy specimens revealed no evidence of
tumor.
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24. Dr. Naveed AshrafRadiologic Pictorial Review
57-year-old man with ringlike peptic stricture that was judged to be benign
by observers. A, Left posterior oblique double-contrast esophagogram
obtained with patient upright shows benign-appearing stricture as
smooth, symmetric ringlike constriction (arrow) with slightly tapered
borders at gastroesophageal junction. Note resemblance to Schatzki’s ring.
B, Right anterior oblique single-contrast esophagogram obtained with
patient prone shows ringlike constriction (arrow) above hiatal hernia.
Endoscopy (not shown) revealed ringlike peptic stricture, and endoscopic
biopsy specimens revealed no evidence of tumor.
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25. Dr. Naveed AshrafRadiologic Pictorial Review
53-year-old man with ringlike peptic stricture (seen only on singlecontrast
esophagogram) that was judged to be benign by observers. A, Left
posterior oblique double-contrast esophagogram obtained with patient
upright shows no definite stricture, but distal esophagus is not optimally
distended. B, Right anterior oblique single-contrast esophagogram
obtained with patient prone shows benign-appearing ringlike stricture
(arrow) at gastroesophageal junction above hiatal hernia. Endoscopy (not
shown) revealed short peptic stricture, and endoscopic biopsy specimens
revealed Barrett’s esophagus without evidence of tumor.
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26. Dr. Naveed AshrafRadiologic Pictorial Review
62-year-old woman with midesophageal stricture that was judged to be benign
by observers. Left posterior oblique double-contrast esophagogram obtained
with patient upright shows benign-appearing stricture in mid esophagus as
concentric segment of narrowing (arrows) with smooth contour and tapered
borders. Endoscopy (not shown) also revealed benign-appearing stricture in mid
esophagus, and endoscopic biopsy specimens revealed no evidence of tumor.
Because patient had history of radiation therapy for lung carcinoma, this stricture
is presumed to have been radiation induced. (Note surgical clips from prior left
upper lobectomy.)
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27. Dr. Naveed AshrafRadiologic Pictorial Review
71-year-old man with distal esophageal stricture that was judged to be
malignant by observers. Left posterior oblique double-contrast
esophagogram obtained with patient upright shows malignant-appearing
stricture (arrows) in distal esophagus. Narrowed segment has markedly
irregular contour with areas of nodularity and ulceration. Endoscopic
biopsy specimens revealed esophageal adenocarcinoma.
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28. Dr. Naveed AshrafRadiologic Pictorial Review
55-year-old woman with peptic stricture that was judged to be equivocal
by observers. Left posterior oblique double-contrast esophagogram
obtained with patient upright shows that stricture (black arrows) in distal
esophagus has some benign features with tapered proximal margins and
some malignant features with irregular contour and tiny areas of
ulceration (white arrows). Endoscopy (not shown) revealed peptic stricture
in distal esophagus with associated reflux esophagitis, but endoscopic
biopsy specimens revealed no evidence of tumor.
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29. Dr. Naveed AshrafRadiologic Pictorial Review
67-year-old man with peptic stricture that was judged to be equivocal by
observers. Left posterior oblique double-contrast esophagogram obtained
with patient upright shows that stricture (white arrow) in distal esophagus
has some benign features with tapered distal margins and some malignant
features with abrupt proximal margins (black arrows) and marked
asymmetry. Endoscopy (not shown) revealed benign peptic stricture in
distal esophagus, and endoscopic biopsy specimens revealed Barrett’s
esophagus without evidence of tumor.
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30. Dr. Naveed AshrafRadiologic Pictorial Review
58-year-old man with upper esophageal stricture that was judged to be
equivocal by observers. Right posterior oblique double-contrast esophagogram
obtained with patient upright shows that stricture (white arrow) in upper
esophagus has some benign features with tapered distal margins and smooth
contour and some malignant features with abrupt proximal margins (black
arrows). Endoscopy (not shown) revealed malignant-appearing stricture in upper
esophagus, but endoscopic biopsy specimens could not be obtained because of
degree of obstruction. This patient was known to have undergone
esophagogastrectomy for esophageal carcinoma; therefore, endoscopic findings
were attributed to recurrent or metachronous carcinoma.
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