Difference between revisions of "Oesophageal Stricture"

Revision as of 11:43, 28 June 2010

Typical Signalment

Any age group can be affected
Animals with oesophagitis
Young animals with congenital hiatal hernias
Poor positioning during anaesthesia

Description

An oesophageal stricture is an abnormal circumferential narrowing of the lumen secondary to severe oesophagitis. A deep wall injury results followed by healing by fibrosis. The most important causes are:

Chemical injury from swallowed substances
Gastro-oesophageal reflux
Foreign body
Oesophageal surgery
Neoplasia
Oesophageal abscesses

Diagnosis

Clinical Signs

Depend on the severity and extent of the stricture but include:

Regurgitation shortly after feeding (may then attempt to re-ingest the regurgitant)
Anorexia
Weight loss

Oesophageal Stricture Oesophagoscopy - Copyright David Walker RVC

Oesophageal Stricture Flouroscopy - Copyright David Walker RVC

Malnutrition
Ptyalism
Aspiration pneumonia (with associated pulmonary signs such as wheezing and crackling on lung auscultation)
Liquid food better tolerated than solid food.

Diagnostic Imaging

Fibrosing strictures must be differentiated from vascular ring anomalies, oesophagitis, intraluminal and extraluminal masses. This can be done with survey and contrast radiography, endoscopy and ultrasonography.

Survey radiographs are usually unremarkable in animals with benign oesophageal strictures. Barium contrast radiography is normally diagnostic of the disorder and may demonstrate:

Segmental or diffuse narrowing of the oesophagus
Oesphageal dilatation proximal to the site of the stricture

Ultrasonography is not usually useful in diagnosing small benign strictures but may visualise those caused by mass compression.

Oesophagoscopy is used for a definitive diagnosis. It should be used to confirm the site and severity of the stricture and also to exclude the presence of an intraluminal mass.

Treatment

The suspected cause (ie.oesophagitis) should be corrected first. Oral feedings should be withdrawn in patients with severe stricture or oesophagitis. An oesophagostomy tube may be placed in these cases to provide nutritional support.

Medical therapies:

Gastroprotective Drugs
- Oral sucralfate
- Gastric acid secretory inhibitors (cimetidine, ranitidine, omeprazole)
Anti-inflammatory doses of corticosteroids (ie. prednisolone) to prevent fibrosis and re-stricture.

Surgical therapies:

Dilation/widening of the stricture by ballooning or bougienage.
Surgical resection is not recommended because iatrogenic strictures at the anastomotic site are possible.

Prognosis

The shorter the length of oesophagus involved and the quicker the corrective procedure is performed the better the prognosis. Animals with large, mature strictures and those with continued oesophagitis have a guarded prognosis. Long term gastrostomy tubes may be required in some cases.

References

Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition) BSAVA

Merck & Co (2008) The Merck Veterinary Manual

Nelson, R.W. and Couto, C.G. (2009) Small Animal Internal Medicine (Fourth Edition) Mosby Elsevier.

@@ Line 1: / Line 1: @@
-{{OpenPagesTop}}
+{{review}}
-==Introduction==
-[[Image:Oesophageal Stricture.png|thumb|right|300px|An oesophageal stricture observed by oesophagoscopy<br><small> Copyright David Walker 2009 RVC]]</small>
+{{cat}}
-An oesophageal stricture is an abnormal circumferential narrowing of the oesophageal lumen secondary to severe [[Oesophagitis|oesophagitis]].  Deep injuries to the oesophageal wall heal by fibrosis which contracts over time to form the stricture.  Animals may suffer from multiple strictures and the most common sites are within the '''distal high pressure zone''' (close to the lower oesophageal spincter), over the '''base of the heart''' and '''at the thoracic inlet'''.  The oesophagus is narrower at these points and foreign bodies and refluxed ingesta are therefore more likely to accumulate at these locations.  The most important causes of strictures include:
+{{dog}}
-*'''Physical Injury'''
-**Ingestion of [[Oesophageal Foreign Body|'''foreign bodies''']] which lodge in the oesophagus.
+==Typical Signalment==
-**Passage of nasogastric or pharyngostomy '''feeding tubes''' or of large '''endoscopes'''.
+*Any age group can be affected
-**Erosion of the oesophageal wall or extraluminal compression by '''neoplasia''' or '''abscesses'''.
+*Animals with [[Oesophagitis - WikiClinical|oesophagitis]]
-**'''Surgical wounds''' to the oesophagus that heal with a fibrous component.
+*Young animals with congenital [[Hiatal Hernia|hiatal hernias]]
-*'''Chemical Injury'''
+*Poor positioning during [[Anaesthesia|anaesthesia]]
-**'''Gastro-oesophageal reflux''', which may occur with '''general anaesthesia''' or [[Hiatal Hernia|'''hiatal hernias''']].
-**'''Chronic vomiting'''
-**Ingestion of '''caustic''' or '''irritant substances''', including '''doxycycline''' in cats.
-==Signalment==
+==Description==
-The signalment is dependent on the underlying cause of the injury, with animals of all ages having the potential to be affected.  46% of cases occur after general anaesthesia, presumably due to gastro-oesophageal reflux through the relaxed lower oesophageal sphincter and because peristalsis and saliva production are reduced, meaning that refluxed material is not removed or neutralised.
+An oesophageal stricture is an abnormal circumferential narrowing of the lumen secondary to severe [[Oesophagitis - WikiClinical|oesophagitis]]. A deep wall injury results followed by healing by fibrosis. The most important causes are:
+*Chemical injury from swallowed substances
+*Gastro-oesophageal reflux
+*[[Oesophageal Foreign Body|Foreign body]]
+*Oesophageal surgery
+*[[Oesophageal Neoplasia|Neoplasia]]
+*Oesophageal abscesses
 ==Diagnosis==
 ===Clinical Signs===
-The signs observed depend on the severity and extent of the stricture but include:
+Depend on the severity and extent of the stricture but include:
-*'''Regurgitation''' shortly after feeding, often with '''hypersalivation/ptyalism'''.  Liquid foods may be better tolerated than solid food and it is better able to pass through the stricture.
+*Regurgitation shortly after feeding (may then attempt to re-ingest the regurgitant)
-*'''Anorexia''' and resultant '''weight loss'''.
+*Anorexia
-*As with any cause of repeated regurgitation, '''aspiration pneumonia''' may develop with signs of coughing, tachypnoea, dyspnoea and pyrexia.
+*Weight loss
+[[Image:Oesophageal Stricture.png|thumb|right|300px|Oesophageal Stricture Oesophagoscopy - Copyright David Walker RVC]]
+[[Image:Oesophageal Stricture Flouroscopy.png|thumb|right|300px|Oesophageal Stricture Flouroscopy - Copyright David Walker RVC]]
+*Malnutrition
+*Ptyalism
+*Aspiration pneumonia (with associated pulmonary signs such as wheezing and crackling on lung auscultation)
+*Liquid food better tolerated than solid food.
 ===Diagnostic Imaging===
-[[Image:Oesophageal Stricture Flouroscopy.png|thumb|right|300px|An oesophageal stricture observed by fluoroscopy in the region of the thoracic inlet <br><small> Copyright David Walker 2009 RVC]]</small>
+Fibrosing strictures must be differentiated from [[Vascular Ring Anomalies (Persistent Right Aortic Arch: PRAA) - WikiClinical|vascular ring anomalies]], [[Oesophagitis - WikiClinical|oesophagitis]], intraluminal and extraluminal masses. This can be done with survey and contrast radiography, endoscopy and ultrasonography.
-Fibrosing strictures must be differentiated from [[Vascular Ring Anomalies|vascular ring anomalies]], [[Oesophagitis|oesophagitis]] and intraluminal and extraluminal masses. This can be done with plain and contrast radiography, endoscopy and ultrasonography.
-'''Plain radiographs''' are usually unremarkable in animals with simple oesophageal strictures but oral administration of '''barium contrast medium''' may demonstrate '''segmental''' or '''diffuse narrowing''' of the oesophagus and '''oesphageal dilatation''' proximal to the site of the stricture.
+Survey radiographs are usually unremarkable in animals with benign oesophageal strictures. Barium contrast radiography is normally diagnostic of the disorder and may demonstrate:
+*Segmental or diffuse narrowing of the oesophagus
+*Oesphageal dilatation proximal to the site of the stricture
-'''Fluoroscopy''' can be used to great effect to observe the passage of a food bolus along the oesophagus and to define the sites of multiple strictures.
+Ultrasonography is not usually useful in diagnosing small benign strictures but may visualise those caused by mass compression.
-'''Ultrasonography''' is not usually useful in diagnosing simple strictures but may visualise those caused by extraluminal compression by mediastinal neoplasia or abscesses.
+Oesophagoscopy is used for a definitive diagnosis. It should be used to confirm the site and severity of the stricture and also to exclude the presence of an intraluminal mass.
-'''Oesophagoscopy''' may be used to obtain a definitive diagnosis but it requires a general anaesthetic (which may have been the cause of the problem) and, if a large endoscope is passed, this may cause further physical damage to the oesophagus.  Also, endoscopy is not sensitive for the diagnosis of multiple strictures if it is unable to pass through the most proximal.  It can also be used to identify and biopsy any intraluminal masses.
 ==Treatment==
-===Medical Management===
-The suspected cause (ie.[[Oesophagitis|oesophagitis]]) should be corrected initially.  Components of medical management include:
-*'''Withdrawal of oral food for 2-3 days''' as standard but, if the inflammation is severe or rupture has occurred, a '''gastrostomy tube''' may be required.
-*'''Oral sucralfate suspension''' is thought to bind to the base of any ulcers, to stimulate epithelial repair and to neutralise any refluxed gastric juices.
-*'''Gastric acid secretory inhibitors''' (e.g. ranitidine, omeprazole) can be useful in cases of gastro-oesophageal reflux.
-*'''Metaclopramide''', a promotility drug that increases the tone of the lower oesophageal sphincter, may also be used to manage gastro-oesophageal reflux but not if oesophageal motility is thought to be impaired (i.e., if megaoesophagus is present).
-*'''Broad spectrum intra-venous bactericidal antibiotics''' may be required in animals with severe oesophagitis or aspiration pneumonia.  Coupage and nebulisation may be useful adjunctive treatments for aspiration pneumonia and it may be necessary to provide oxygen to dyspnoeic animals.
-*'''Analgesia''' should be provided to encourage animals to eat after 2-3 days.
-*Anti-inflammatory doses of [[Steroids|corticosteroids]] (such as prednisolone) may be used to prevent fibrosis and further stricture formation in acute injuries but caution should be exercised if the animal has concurrent aspiration pneumonia.
-===Surgical Management===
-Surgical intervention usually involves gradually stretching the site of the stricture until the luminal diameter returns to normal.  Since flow increases as the fourth power of the radius (according to the law of LaPlace), even small increases in diameter can produce significant improvements in clinical signs.  Multiple procedures (4-12) are usually required to achieve acceptable results.  Bougeinage and balloon catheters are the methods used most commonly.
-'''Bougeinage''' involves the passage of conical metal rods of increasing size along the oesophagus but alternatively, a '''balloon catheter''' can be advanced along and oesophagus and inflated at the site of the stricture.  This technique exerts pressure more evenly on the entire stricture, especially if it is not circumferential.
+The suspected cause (ie.[[Oesophagitis - WikiClinical|oesophagitis]]) should be corrected first.
+Oral feedings should be withdrawn in patients with severe stricture or oesophagitis. An oesophagostomy tube may be placed in these cases to provide nutritional support.
-'''Surgical resection and anastomosis''' is not recommended because iatrogenic strictures may form at the anastomotic site.  A simpler '''oesophagoplasty''' (similar to pyloroplasty for pyloric stenosis) may be performed, where the stricture is incised longitudinally and sutured transversely to increase the luminal diameter.
+Medical therapies:
+*[[Gastroprotective Drugs]]
+**Oral sucralfate
+**Gastric acid secretory inhibitors (cimetidine, ranitidine, omeprazole)
+*Anti-inflammatory doses of [[Steroids|corticosteroids]] (ie. prednisolone) to prevent fibrosis and re-stricture.
-Anti-inflammatory doses of corticosteroids should again be used during these procedures to try to prevent re-stricturing.
+Surgical therapies:
+*Dilation/widening of the stricture by ballooning or bougienage.
+*Surgical resection is not recommended because iatrogenic strictures at the anastomotic site are possible.
 ==Prognosis==
-The shorter the length of oesophagus involved and the quicker the corrective procedure is performed, the better the prognosis.  Animals with large, mature strictures and those with continued oesophagitis have a guarded prognosis and long-term gastrostomy tubes may be required in these cases.
+The shorter the length of oesophagus involved and the quicker the corrective procedure is performed the better the prognosis.
+Animals with large, mature strictures and those with continued oesophagitis have a guarded prognosis. Long term gastrostomy tubes may be required in some cases.
-{{Learning
-|Vetstream = [https://www.vetstream.com/canis/Content/Disease/dis00639.asp, Oesophageal stricture]
-|literature search = [http://www.cabdirect.org/search.html?q=%28title%3A%28oesophag*%29+OR+title%3A%28esophag*%29%29+AND+title%3A%28stricture%29 Oesophageal Stricture publications]
-}}
 ==References==
 *Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) '''BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition)''' ''BSAVA''
-*Merck & Co (2008) '''The Merck Veterinary Manual'''''Merial
-*Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''.
+*Merck & Co (2008) '''The Merck Veterinary Manual'''
-{{review}}
+*Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''.
+[[Category:Oesophagus_-_Pathology]][[Category:To_Do_-_Clinical]]
-{{OpenPages}}
-[[Category:Oesophagus_-_Pathology]]
-[[Category:Expert_Review - Small Animal]]
-[[Category:Oesophageal Diseases - Dog]][[Category:Oesophageal Diseases - Cat]]