1975, British Journal of Radiology, 48, 646-648
Caustic strictures of the oesophagus By Hilary Skene-Smith, M.R.C.P., F.R.C.R. Department of Radiology, University of Malaya, Kuala Lumpur, Malaysia (Received October, 1974 and in revised form January, 1975) ABSTRACT
Twenty-two cases of corrosive oesophageal strictures were reviewed and divided into annular, short segment and long segment lesions. The lower third of the oeseophagus was involved in all the long segment strictures, but with sparing of the extreme distal portion in most. Irregularity of the stricture walls with an appearance similar to reported cases of intramural diverticulosis is a common finding but smooth strictures can also occur.
This was demonstrated in 11 cases, where the lower oesophagus was involved by long segment strictures.
Caustic ingestion is rare in the the United Kingdom (Thompson, 1968), but occurs quite commonly in Europe, the United States and the Far East (Hardin, 1956; Hong, Steel and Dietrick, 1964). Increasing travel makes it inevitable that more patients will be seen with corrosive strictures. This paper shows some of the radiological features, particularly the sites involved, and the appearance of "intramural diverticulosis" and irregularity of the wall in severe strictures. MATERIAL
Twenty-two patients were seen at University Hospital between 1968 and 1974. The age at referral ranged between 15 years and 62 years, that at ingestion from one year to 45 years. Sixteen were females and six males. Ingestion was suicidal in nine cases, accidental in eight. RADIOLOGICAL FEATURES
Strictures were classified according to the site involved in the upper, middle or lower third of the oesophagus only, affecting all areas, or, just the middle and lower thirds. Multiple strictures occurred in three patients. The strictures were also graded according to type using a modification of Marchand's classification (Marchand, 1955). (1) Annular. (2) Short segment—arbitrarily denned as less than half an inch in length. (3) Long segment—these are tubular strictures of over half an inch length. Table I shows these features and also the presence of irregularity of the oesophageal wall in 12 patients, with long strictures. Another feature emphasized by Marchand was sparing of the extreme lower end of the oesophagus. 646
FIG. 1. Three smooth annular strictures.
AUGUST
1975
Caustic strictures of the oesophagus
FIG. 2. Long irregular stricture.
FIG. 3. Irregular stricture with false passages and "diverticula"
DISCUSSION
Although caustic oesophageal strictures have occurred for many years confusion over a working classification persists. Some textbooks state that the strictures are usually long and tapering, may be multiple and occur most frequently at the sites of anatomic narrowing especially at the crossing of the left main bronchus or at the lower end (Paul and Juhl, 1972; Sutton, 1969). This is classic teaching
(Thompson, 1968). Another textbook emphasizes involvement of the middle and lower parts (British Authors, 1969), and this is similar to the findings here. Some of the difficulty is related to the definition of the various parts of the oesophagus, therefore in this paper arbitrary division into thirds is used. All the long segment strictures have affected the lower third with a variable proximal extension depending on the length of the lesion. The extreme
647
VOL.
48, No. 572 Hilary Skene-Smith TABLE I ANALYSIS OF STRICTURES
Number of cases Annular stricture
Short segment
Long segment
Smooth wall
Irregular wall
Upper third
1
1
0
2
0
Middle third
1
1
0
2
0
Lower third
1
0
3
3
1
Whole length
—
—
5
0
5
Middle and lower thirds
2
1
8
3
6
distal oesophagus is often spared. This area may be difficult to demonstrate due to the proximal stricture (Marchand, 1955). Short segment and annular strictures may affect any part of the oesophagus (Fig. 1). Irregularity of the walls of the long segment strictures was present in all cases, with oral feeding. The two patients with long term gastrostomies had smooth walled lesions. The irregularity and presence of false passages increased with obstruction and dilatations (Fig. 2). An extremely ragged outline also occurred without instrumentation. This resembles intramural diverticulosis (Fig. 3) and is not surprising as in the reported cases all the patients had dysphagia and both chronic inflammation and raised intraluminal pressure were implicated (Mendl, McKay and Tanner, 1960; Hodes, Atkins and Hodes, 1966; Culver and Chaudhari, 1967; Zatzkin, Green and La Vine, 1968; Troupin, 1968; Creely and Trail, 1970; Weller and Lutsker, 1971; Smulewicz and Dorfman, 1971; Weller, 1972; Lane, 1972; Mendl, Montgomery and Stephenson, 1973; Wightman and Wright, 1974). Both these factors are present in caustic strictures.
HARDIN, J. C , 1956. Caustic burns of the esophagus. American Journal of Surgery, 91, 742-748. HODES, P. J., ATKINS, J. P., and HODES, B. L., 1966.
Esophageal intramural diverticulosis. American Journal of Roentgenology, 96, 411-413. HONG, P. W., STEEL, D. J., and DIETRICK, R. B., 1964.
The use of colon in the surgical treatment of benign stricture of the esophagus. Annals of Surgerv, 160, 202-209. MARCHAND, P., 1955. Caustic strictures of the oesophagus. Thorax, 70,171-181. MENDL, K., DARRAGH MONTGOMERY, R., and STEPHENSON,
P. F., 1973. Segmental intramural diverticulosis associated with and confined to a spastic area of muscular hypertrophy in a columnar lined oesophagus. Clinical Radiology, 24, 440-444. MENDL, K., MCKAY, J. M., and TANNER, C. H. 1960. Intra-
mural diverticulosis of the oesophagus and RokitanskyAshhoff sinuses in the gall bladder. British Journal of Radiology, 33, 496-501. PAUL, L. W., and JUHL, J. K., 1972. The Essentials of the
Roentgen Interpretation, p. 501 (Harper and Row). SUTTON, D., 1969. A Textbook of Radiology, pp. 627-628 (E. & S. Livingstone). SMULEWICZ, J. J., and DORFMAN, J., 1971. Esophageal
intramural diverticulosis: a re-evaluation. Radiology, 101, 527-529. THOMPSON, D. T., 1968. Lye stricture of the oesophagus in an infant. Journal of the Royal College of Surgeons of Edinburgh, 13, 330-332. TROUPIN, R. H., 1968. Intramural esophageal diverticulosis and moniliasis. American Journal of Roentgenology, 104, 613-616. WELLER, M. H., 1972. Intramural diverticulosis of the REFERENCES esophagus: report of a case in a child. Journal of PediaBRITISH AUTHORS, 1969. A Textbook of X-ray Diagnosis, trics, 80, 281-285. eds. S. C. Shanks and P. Keeley, Vol. 4, p. 61 (H. K. Lewis & Co. Ltd.). WELLER, M. H., and LUTZKER, S. A., 1971. Intramural diverCRAMER, K. R., 1972. Intramural diverticulosis of the ticulosis of the esophagus associated with post-operative oesophagus. British Journal of Radiology, 45, 857—859. hiatal hernia, alkaline esophagitis and esophageal stricture. Radiology, 98, 373-373. CREELY, J. J., and TRAIL, M. L., 1970. Intramural diverticulosis of the esophagus. Southern Medical Journal, 63, WIGHTMAN, A. J. A., and WRIGHT, E. A., 1974. Intramural oesophageal diverticulosis: a correlation of radiological 1257-1260. and pathological findings. British Journal of Radiology, CULVER, G. J., and CHAUDHARI, K. R., 1967. Intramural 47, 496-498. esophageal diverticulosis. American Journal of Roentgenology, 99, 210-211. ZATZKIN, H. R., GREEN, S., and LA VINE, J. J., 1968. LANE, J. W., 1972. Intramural esophageal diverticulosis— Esophageal intramural diverticulosis. Radiology, 90, 1193-1194. A case report. Journal of the Arkansas Medical Society, 69, 87-90.
648
Caustic strictures of the oesophagus By Hilary Skene-Smith, M.R.C.P., F.R.C.R. Department of Radiology, University of Malaya, Kuala Lumpur, Malaysia (Received October, 1974 and in revised form January, 1975) ABSTRACT
Twenty-two cases of corrosive oesophageal strictures were reviewed and divided into annular, short segment and long segment lesions. The lower third of the oeseophagus was involved in all the long segment strictures, but with sparing of the extreme distal portion in most. Irregularity of the stricture walls with an appearance similar to reported cases of intramural diverticulosis is a common finding but smooth strictures can also occur.
This was demonstrated in 11 cases, where the lower oesophagus was involved by long segment strictures.
Caustic ingestion is rare in the the United Kingdom (Thompson, 1968), but occurs quite commonly in Europe, the United States and the Far East (Hardin, 1956; Hong, Steel and Dietrick, 1964). Increasing travel makes it inevitable that more patients will be seen with corrosive strictures. This paper shows some of the radiological features, particularly the sites involved, and the appearance of "intramural diverticulosis" and irregularity of the wall in severe strictures. MATERIAL
Twenty-two patients were seen at University Hospital between 1968 and 1974. The age at referral ranged between 15 years and 62 years, that at ingestion from one year to 45 years. Sixteen were females and six males. Ingestion was suicidal in nine cases, accidental in eight. RADIOLOGICAL FEATURES
Strictures were classified according to the site involved in the upper, middle or lower third of the oesophagus only, affecting all areas, or, just the middle and lower thirds. Multiple strictures occurred in three patients. The strictures were also graded according to type using a modification of Marchand's classification (Marchand, 1955). (1) Annular. (2) Short segment—arbitrarily denned as less than half an inch in length. (3) Long segment—these are tubular strictures of over half an inch length. Table I shows these features and also the presence of irregularity of the oesophageal wall in 12 patients, with long strictures. Another feature emphasized by Marchand was sparing of the extreme lower end of the oesophagus. 646
FIG. 1. Three smooth annular strictures.
AUGUST
1975
Caustic strictures of the oesophagus
FIG. 2. Long irregular stricture.
FIG. 3. Irregular stricture with false passages and "diverticula"
DISCUSSION
Although caustic oesophageal strictures have occurred for many years confusion over a working classification persists. Some textbooks state that the strictures are usually long and tapering, may be multiple and occur most frequently at the sites of anatomic narrowing especially at the crossing of the left main bronchus or at the lower end (Paul and Juhl, 1972; Sutton, 1969). This is classic teaching
(Thompson, 1968). Another textbook emphasizes involvement of the middle and lower parts (British Authors, 1969), and this is similar to the findings here. Some of the difficulty is related to the definition of the various parts of the oesophagus, therefore in this paper arbitrary division into thirds is used. All the long segment strictures have affected the lower third with a variable proximal extension depending on the length of the lesion. The extreme
647
VOL.
48, No. 572 Hilary Skene-Smith TABLE I ANALYSIS OF STRICTURES
Number of cases Annular stricture
Short segment
Long segment
Smooth wall
Irregular wall
Upper third
1
1
0
2
0
Middle third
1
1
0
2
0
Lower third
1
0
3
3
1
Whole length
—
—
5
0
5
Middle and lower thirds
2
1
8
3
6
distal oesophagus is often spared. This area may be difficult to demonstrate due to the proximal stricture (Marchand, 1955). Short segment and annular strictures may affect any part of the oesophagus (Fig. 1). Irregularity of the walls of the long segment strictures was present in all cases, with oral feeding. The two patients with long term gastrostomies had smooth walled lesions. The irregularity and presence of false passages increased with obstruction and dilatations (Fig. 2). An extremely ragged outline also occurred without instrumentation. This resembles intramural diverticulosis (Fig. 3) and is not surprising as in the reported cases all the patients had dysphagia and both chronic inflammation and raised intraluminal pressure were implicated (Mendl, McKay and Tanner, 1960; Hodes, Atkins and Hodes, 1966; Culver and Chaudhari, 1967; Zatzkin, Green and La Vine, 1968; Troupin, 1968; Creely and Trail, 1970; Weller and Lutsker, 1971; Smulewicz and Dorfman, 1971; Weller, 1972; Lane, 1972; Mendl, Montgomery and Stephenson, 1973; Wightman and Wright, 1974). Both these factors are present in caustic strictures.
HARDIN, J. C , 1956. Caustic burns of the esophagus. American Journal of Surgery, 91, 742-748. HODES, P. J., ATKINS, J. P., and HODES, B. L., 1966.
Esophageal intramural diverticulosis. American Journal of Roentgenology, 96, 411-413. HONG, P. W., STEEL, D. J., and DIETRICK, R. B., 1964.
The use of colon in the surgical treatment of benign stricture of the esophagus. Annals of Surgerv, 160, 202-209. MARCHAND, P., 1955. Caustic strictures of the oesophagus. Thorax, 70,171-181. MENDL, K., DARRAGH MONTGOMERY, R., and STEPHENSON,
P. F., 1973. Segmental intramural diverticulosis associated with and confined to a spastic area of muscular hypertrophy in a columnar lined oesophagus. Clinical Radiology, 24, 440-444. MENDL, K., MCKAY, J. M., and TANNER, C. H. 1960. Intra-
mural diverticulosis of the oesophagus and RokitanskyAshhoff sinuses in the gall bladder. British Journal of Radiology, 33, 496-501. PAUL, L. W., and JUHL, J. K., 1972. The Essentials of the
Roentgen Interpretation, p. 501 (Harper and Row). SUTTON, D., 1969. A Textbook of Radiology, pp. 627-628 (E. & S. Livingstone). SMULEWICZ, J. J., and DORFMAN, J., 1971. Esophageal
intramural diverticulosis: a re-evaluation. Radiology, 101, 527-529. THOMPSON, D. T., 1968. Lye stricture of the oesophagus in an infant. Journal of the Royal College of Surgeons of Edinburgh, 13, 330-332. TROUPIN, R. H., 1968. Intramural esophageal diverticulosis and moniliasis. American Journal of Roentgenology, 104, 613-616. WELLER, M. H., 1972. Intramural diverticulosis of the REFERENCES esophagus: report of a case in a child. Journal of PediaBRITISH AUTHORS, 1969. A Textbook of X-ray Diagnosis, trics, 80, 281-285. eds. S. C. Shanks and P. Keeley, Vol. 4, p. 61 (H. K. Lewis & Co. Ltd.). WELLER, M. H., and LUTZKER, S. A., 1971. Intramural diverCRAMER, K. R., 1972. Intramural diverticulosis of the ticulosis of the esophagus associated with post-operative oesophagus. British Journal of Radiology, 45, 857—859. hiatal hernia, alkaline esophagitis and esophageal stricture. Radiology, 98, 373-373. CREELY, J. J., and TRAIL, M. L., 1970. Intramural diverticulosis of the esophagus. Southern Medical Journal, 63, WIGHTMAN, A. J. A., and WRIGHT, E. A., 1974. Intramural oesophageal diverticulosis: a correlation of radiological 1257-1260. and pathological findings. British Journal of Radiology, CULVER, G. J., and CHAUDHARI, K. R., 1967. Intramural 47, 496-498. esophageal diverticulosis. American Journal of Roentgenology, 99, 210-211. ZATZKIN, H. R., GREEN, S., and LA VINE, J. J., 1968. LANE, J. W., 1972. Intramural esophageal diverticulosis— Esophageal intramural diverticulosis. Radiology, 90, 1193-1194. A case report. Journal of the Arkansas Medical Society, 69, 87-90.
648
