Endoscopic signs of esophageal strictures

A stricture is a clearly defined narrowing that does not stretch under air pressure. In 70-73% of cases, esophageal strictures occur as a result of chemical burns of the esophagus. In other cases, strictures develop as a result of reflux esophagitis, radiation therapy for thyroid cancer, and damage to the esophagus during surgery. Strictures develop if the muscular layer of the esophagus is affected. The degree of narrowing depends on the concentration of the solution, the extent of the lesion, and the state of the immune system.

Classification of esophageal strictures (Ratner).

1. By localization of stricture.
   1. High strictures. In the area of the entrance to the esophagus and the cervical region.
   2. Median strictures. Lower cervical spine, aortic arch area and tracheal bifurcation.
   3. Low strictures (cardiac).
   4. Combined strictures.
2. By the extent of the lesion.
   1. Short (membranous or filmy). One scar in the form of a fold.
   2. Circular. Length up to 3 cm.
   3. Tubular. Length more than 3 cm.
   4. Bead-shaped. Alternation of narrowed areas with normal ones.
   5. Total lesion of the esophagus.
3. By the form of suprastenotic expansion.
   1. Conical.
   2. Saccular.
4. Regarding complications.
   1. False diverticula.
   2. False moves.
   3. Cicatricial shortening.
   4. Fistulas.

Classification of the degree of esophageal obstruction.

1. Selective. The diameter of the constriction is 1.0-1.5 cm. Almost all food passes, except for coarse food.
2. Compensated. The diameter of the stenosis is 0.3-0.5 cm. Semi-liquid and thoroughly processed food passes. Suprastenotic expansion of the esophagus appears.
3. Subcompensated. Diameter less than 0.3 cm. Only liquid and oil pass through.
4. Reversible. Complete obstruction of the passage of food and liquid through the esophagus, but after a course of treatment, patency is restored.
5. Complete obliteration.

Classification by the nature of the inflammatory process in the stricture area.

• Epithelialized strictures:
  • without inflammation,
  • catarrhal esophagitis,
  • fibrinous esophagitis,
  • erosive esophagitis.
• Nonepithelialized strictures:
  • catarrhal ulcerative esophagitis,
  • erosive and ulcerative esophagitis.

The examination begins with a standard device, which, if necessary, can be replaced with a pediatric device, a choledochoscope, a bronchoscope, or a babyscope (diameter 2.4 mm) can be used. The extent of the lesion is determined by farcept, using a babyscope. The diameter of the narrowing is determined either by focusing on the diameter of the device, or using the balloon method.

The stricture looks like a dense cicatricial funnel, round, oval or rectangular in shape, the lumen can sometimes be covered by a fold of unchanged mucous. A clear transition of the unchanged mucous into the stricture is visible. In strictures with a lumen diameter of less than 0.6 cm, the epithelium is absent for a month after the burn. Such a stricture is covered with a thick fibrin coating. After its removal, bright red (cicatricial) tissue is exposed, bleeding, less often pale walls (mature cicatricial tissue).

Criteria for distinguishing cicatricial strictures from cancerous ones

1. Cicatricial strictures are characterized by stretching of the stricture wall during air insufflation.
2. Cicatricial strictures are characterized by a clear transition from normal mucosa to scar tissue.
3. The shape of the narrowing in cicatricial strictures is round or oval.
4. In case of cancerous narrowing, taking a biopsy presents great difficulties - the tissue is of cartilaginous density.

Cicatricial strictures with a narrowing diameter of more than 0.6 cm are epithelialized. The epithelial lining is pale, soldered to the underlying tissues. When insufflated with air, the walls of the stricture are partially stretched, unlike cancer. Cancer in a cicatricial stricture resembles the growth of granulations, but not red, but white-gray in color, dense during instrumental palpation. Biopsy should be taken from granulations.

Peculiarities of ulceration in cicatricial strictures

1. There is no infiltrative ridge around the ulcer.
2. The ulcer border is represented by an epithelial lining, hyperemic along the edge and fused with the underlying scar tissue.
3. The surface of the ulcers is smooth, clear, and has a fibrinous coating.
4. Ulcers are round, oval or polygonal in shape.

In later stages (more than 1.5 months), dense, white scar tissue is visible.

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