Upper Gastrointestinal Stenoses Malignant Strictures

■ Causes and Sites of Occurrence

Stenoses in the upper gastrointestinal tract can result from benign and malignant diseases. The causes are listed in Table 4.13. The most frequent site of occurrence is the esophagus. A less common site is the gastric outlet. Significant stenoses of the duodenum, usually a result of adjacent malignancies, are very rare (Table 4.14 ).

Table 4.13 Causes of upper gastrointestinal stenoses

- Inflammatory, cicatricial: peptic stricture, corrosive ingestion, radiation

- Neurogenic: achalasia

- Postoperative: fundoplication, tight anastomosis after resection

- Postinterventional: banding of esophageal varices

- Esophageal carcinoma

- Bronchial carcinoma compressing the esophagus

- Malignant stricture of the gastric outlet

■ Treatment Options

Treatment options for upper gastrointestinal stenoses include surgical techniques, endoscopic techniques to restore patency, and feeding tube placement (PEG, see p. 160). The treatment of choice depends on the benign or malignant nature of the stenosis, its location, the operability of the patient, and the technical capabilities of the department. The endoscopic treatment options for upper gastrointestinal stenoses are reviewed in Table 4.15.

■ Malignant Strictures

Esophageal and bronchial carcinoma are the most frequent causes of malignant strictures in the upper gastrointestinal tract.

Less than 50% of squamous cell carcinomas of the esophagus are operable when diagnosed. The five-year survival rate is very poor, at less than 20%. One should be cautious in selecting these patients for palliative procedures.

Table 4.14 Location of upper gastrointestinal stenoses

Table 4.14 Location of upper gastrointestinal stenoses

Table 4.15 Treatment of upper gastrointestinal stenoses

Endoscopic treatment options

Table 4.15 Treatment of upper gastrointestinal stenoses

Reflux Stricture

Fig. 4.42 Esophageal stricture caused by squamous cell carcinoma

► Stent implantation (treatment of choice)

► Tube implantation

► Laser therapy (especially for short strictures)

► Bougie dilation (as a prelude to stenting, intubation, or laser therapy)

Advanced bronchial carcinoma can lead to severe compression and infiltration of the esophagus with luminal obstruction.

Endoscopic treatment options

► Stent implantation

► Tube implantation

► Caution: Laser treatment is contraindicated due to the risk of fistula formation.

Fig. 4.44 Bronchial carcinoma. The tumor has infiltrated and compressed the esophagus

Fig. 4.42 Esophageal stricture caused by squamous cell carcinoma

Fig. 4.43 Squamous cell carcinoma. Recurrent tumor

Fig. 4.44 Bronchial carcinoma. The tumor has infiltrated and compressed the esophagus

■ Peptic Esophageal

Stricture (Fig. 4.45)

Peptic strictures of the esophagus are a complication of untreated reflux esophagitis.

■ Gastric Outlet Stricture

Gastric outlet stricture is usually a complication of recurrent gastric ulcers.

Malignant Esophageal Stricture

Fig. 4.48 Fundoplication

Endoscopic treatment options

► Balloon dilation

Fig. 4.46 Stricture due to caustic ingestion

Fig. 4.45 Peptic stricture

■ Corrosive Ingestion

Strictures can develop as a late complication of corrosive ingestion, causing lumi-nal obstruction.

Radiation injury of the esophagus following radiotherapy to the lung or mediastinum can lead to ci-catricial strictures.

Fig. 4.46 Stricture due to caustic ingestion

Endoscopic treatment options

► Bougie dilation

► Balloon dilation

Endoscopic treatment options

► Bougie dilation

Fig. 4.47 Achalasia

■ Fundoplication

Postoperative stenosis can occur as a possible complication of fundoplication.

■ Anastomotic Stenosis

The anastomoses that are performed in upper gastrointestinal resections (gastric resection, cardiectomy) may become stenotic, producing obstructive symptoms.

Fig. 4.48 Fundoplication

Fig. 4.49 Tight anastomosis following esophageal resection

Endoscopic treatment options

► Bougie dilation

► Balloon dilation

Endoscopic treatment options

► Bougie dilation

► Balloon dilation

Fig. 4.50 Stricture following multiple sclerotherapy injections

Fig. 4.49 Tight anastomosis following esophageal resection

Fig. 4.50 Stricture following multiple sclerotherapy injections

Achalasia is a neurogenic disorder characterized by a failure of relaxation of the lower esophageal sphincter.

B Endoscopic treatment options

► Balloon dilation (treatment of choice)

► Injection of botulinum toxin (experimental)

■ Banding and Sclerotherapy of Varices (Fig. 4.50)

Cicatricial strictures can develop as a late complication following the banding or sclerotherapy of esophageal varices.

Endoscopic treatment options

► Bougie dilation

► Balloon dilation

Was this article helpful?

0 0

Post a comment