Stenosis of the Esophagus.
Synonyms:—Stricture of the esophagus; esophageal stricture.
Definition:—A secondary condition, resulting in the reduction of the lumen of the esophagus, either by external pressure, by fibrous or other degeneration of the structure of its walls, or by cicatricial contraction, after local injury or ulceration.
Etiology:—A case which the writer observed very recently resulted from extraneous adhesive inflammation, there being but little disease within the tube. The use of caustic potash, carbolic acid and arsenic for suicidal purposes is probably the commonest cause. The ingestion of any corrosive substance will induce this condition, from cicatricial contraction. Ulceration as the result of other disease or the presence of malignant disease causes stricture. The condition usually occurs behind the cricoid cartilage, opposite the point of bifurcation of the trachea. It may also be caused by the presence of a polypus within the esophagus, or from the pressure of a tumor external but contiguous to it, or from an aneurism. A gunshot or knife wound or other direct injury to the esophagus may result in contraction during the repair of the injury. Contractions are described as single or multiple, symmetrical or asymmetrical annular or cylindrical.
Symptomatology:—The first evidence, which is usually overlooked, is mild difficulty in swallowing. This slowly and steadily increases in proportion to the severity of the disease. Other symptoms of the condition will vary according to the character of the causes which have produced the disease, upon the location of the obstruction, and upon its completeness. Early in the history of the case there is a sense of constriction in the neck or in the lower part of the throat, with a dull pain, which becomes tensive upon swallowing solid substances. When the stenosis becomes extreme, regurgitation of the food may at once take place, but after the condition has existed for a considerable time, as is elsewhere stated, dilatation occurs and the food may be retained for two or three hours, to be then rejected in a state of partial decomposition. This substance will contain no gastric juice or products of digestion, thus showing that it did not reach the stomach. If the mucous lining of the esophagus be denuded, or if there is a local ulcer, the pain after the food is swallowed may be excruciating. It will be observed by an intelligent patient that there is not only mechanical obstruction, but that difficulty in swallowing also results from weakness of the muscular structure of the esophagus.
As the condition continues, the patient's health is undermined, he becomes emaciated, and if there is malignant disease, the characteristic cachexia, with continued dull, heavy pain and increasing dysphagia, are prominent symptoms.
Diagnosis:—It is not difficult to determine that there is obstructed swallowing, but it is not a simple thing to ascertain, in all cases, whether the symptoms are due to simple obstruction or to dilatation of the esophagus. A bougie introduced into the esophagus will pass the obstruction with difficulty, if at all. In case of dilatation the bougie can be moved about above the point of constriction with some freedom. Where dilatation is present, which is not caused by stricture, the sound will easily enter the stomach. An effort should be made, upon the introduction of the bougie, not only to determine the presence of the stricture, but to ascertain, if possible, the cause of the stricture. In all cases hysterical spasms should be excluded.
Prognosis:—These cases seldom result favorably, as the causes are usually extreme and severe. The prognosis should always be guarded.
Treatment:—Medical treatment is of no avail. The galvanic current, properly applied, by an experienced physician, is sometimes of much service. In reflex cases the cause may be removed, when found, by proper medicinal treatment: medicine will also benefit hysterical cases. Usually surgical treatment only is productive of good results.
Bougies properly introduced will overcome some of the cases if the treatment is systematically and persistently conducted. They are especially valuable in overcoming cicatricial contraction. Where there is malignant disease this course is seldom available, often causing great pain and an aggravation of all of the symptoms. Where the obstruction is complete, a surgical operation must be performed as a final resort.