DOI: 10.1148/rg.234025717
(Radiographics. 2003;23:897-909.)
© RSNA, 2003
Radiologic Diagnosis of Benign Esophageal Strictures: A Pattern Approach1
Pia Luedtke, BA,
Marc S. Levine, MD,
Stephen E. Rubesin, MD,
Donald S. Weinstein, MD and
Igor Laufer, MD
1 From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (P.L., M.S.L., S.E.R., I.L.), and the Department of Radiology, Pennsylvania Hospital, Philadelphia, Pa (D.S.W.). Received October 14, 2002; revision requested November 22 and received December 9; accepted December 12. M.S.L. and S.E.R. are consultants with E-Z-Em Co, Inc, Westbury, NY. Address correspondence to M.S.L. (e-mail: levine@oasis.rad.upenn.edu).
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Abstract
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Benign esophageal strictures are a leading cause of dysphagia. Therefore, radiologists have an important role in detecting esophageal strictures and determining their cause. The most common cause of strictures in the distal esophagus is gastroesophageal reflux disease. Reflux-induced ("peptic") strictures may be associated with sacculations, fixed transverse folds, or esophageal intramural pseudodiverticula. In addition, scleroderma, nasogastric intubation, Zollinger-Ellison syndrome, and alkaline reflux esophagitis may be associated with stricture formation in the distal esophagus. Upper and midesophageal strictures may be caused by Barrett esophagus, mediastinal irradiation, ingestion of drugs or caustic substances, congenital esophageal stenosis, skin diseases, or esophageal intramural pseudodiverticulosis. Other unusual causes of esophageal stricture formation include Crohn disease, Candida esophagitis, graft-versus-host disease, eosinophilic esophagitis, Behçet disease, endoscopic sclerotherapy for esophageal varices, and glutaraldehyde contamination at endoscopy. Esophageal strictures are best evaluated with biphasic esophagography that includes both single- and double-contrast spot images. When esophageal strictures are detected at barium examination, the underlying cause can often be determined with a pattern approach that takes into account the clinical history, the appearance and location of the strictures, and the presence of other associated radiographic findings.
© RSNA, 2003
Index Terms: Esophagus, 71.123, 71.744 • Esophagus, stenosis or obstruction, 71.744
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- List the causes of benign esophageal strictures.
- Identify the cause of a benign stricture based on the location and appearance of the stricture and pertinent clinical history.
- Describe the role of barium examination in the evaluation of esophageal strictures.
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Introduction
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Benign strictures of the esophagus are an important cause of dysphagia. They may result from common conditions such as gastroesophageal reflux disease or from rare and complex multisystem disorders. Barium examination has been shown to play a major role in the detection of esophageal strictures. In this article, we present a pattern approach for the diagnosis of benign strictures seen at esophagography that is based on the clinical setting, the location and appearance of the strictures, and the presence of other associated radiographic findings.
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Clinical Aspects
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Chronic or severe esophagitis from a variety of causes may lead to scarring and fibrosis with the development of esophageal strictures. Therefore, the clinical setting is crucial in determining the underlying cause of these strictures. In some cases, the correct diagnosis may be suggested by a temporal relationship between stricture formation and precipitating factors such as mediastinal irradiation, ingestion of caustic substances, and nasogastric intubation. In other cases, important clinical clues may be provided by findings such as high serum gastrin levels in Zollinger-Ellison syndrome, an allergy history or peripheral eosinophilia in eosinophilic esophagitis, or bullous skin eruptions in epidermolysis bullosa dystrophica or benign mucous membrane pemphigoid. Therefore, all strictures should be evaluated in the clinical context in which they develop.
Dysphagia is by far the most common presenting complaint in patients with esophageal strictures. The duration of dysphagia is a useful clinical parameter for differentiating benign from malignant strictures. In general, benign strictures are associated with long-standing, intermittent, nonprogressive dysphagia, whereas malignant strictures are associated with recent onset of rapidly progressive dysphagia and weight loss. However, the subjective site of dysphagia is unreliable for determining the stricture location because some patients with distal strictures have dysphagia that is referred proximally to the sternal notch or even the neck (1). Thus, the entire esophagus should be carefully evaluated with barium examination in all patients with dysphagia, regardless of the subjective site of this symptom.
Administration of a barium tablet is sometimes helpful for demonstrating strictures when esophageal distention is inadequate for routine examination. The barium tablet may lodge above subtle areas of narrowing, allowing recognition of strictures that might otherwise be missed. Also, when rings or strictures are detected at barium examination, objective measurements of luminal diameter may be difficult to obtain with digital fluoroscopic equipment. In such cases, retention of a 12-mm barium tablet above the narrowed segment indicates unequivocally that the ring or stricture is less than 12 mm in diameter.
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Imaging Technique
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Esophageal strictures are best evaluated with biphasic esophagography that includes both double-contrast and single-contrast spot images (2). The single-contrast phase optimizes distention of the esophagus, thereby improving detection of strictures, whereas the double-contrast phase optimizes visualization of the mucosa for nodules, ulcers, or other radiographic findings associated with these strictures. The double-contrast images are obtained as the patient gulps a high-density barium suspension in the upright left posterior oblique position after ingesting an effervescent agent. The single-contrast images are obtained as the patient gulps a low-density barium suspension in the prone right anterior oblique position. Rapid-sequence digital fluoroscopy is helpful for demonstrating strictures in the cervical or upper thoracic esophagus that are difficult to visualize on routine spot images because of rapid passage of the barium bolus.
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Causes of Lower Esophageal Strictures
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Scarring from reflux esophagitis is by far the most common cause of stricture formation in the distal esophagus. Other entities such as scleroderma, nasogastric intubation, Zollinger-Ellison syndrome, and alkaline reflux esophagitis may cause an unusually severe form of reflux-induced injury, resulting in marked distal esophageal strictures.
Gastroesophageal Reflux Disease
Reflux-induced ("peptic") strictures classically appear as smooth, tapered areas of concentric narrowing in the distal esophagus and range from 1 to 4 cm in length (Fig 1) (3,4). However, asymmetric scarring can lead to asymmetric narrowing, often associated with the development of one or more sacculations that result from outward ballooning of the esophageal wall between areas of fibrosis (Figs 2, 3) (4). These sacculations can sometimes be mistaken for ulcers but tend to have a more rounded appearance and a more changeable configuration at fluoroscopy. Longitudinal scarring from reflux esophagitis can also lead to the development of fixed transverse folds in the region of the stricture with barium trapped between the folds, producing a characteristic "stepladder" appearance (Fig 4) (5). These fixed transverse folds can sometimes be mistaken for the delicate transverse striations that are often observed as a transient finding on double-contrast images obtained in patients with a "feline" esophagus. However, these fixed transverse folds tend to be wider than those in the feline esophagus and usually do not extend more than halfway across the esophagus. Other peptic strictures may be associated with a focal cluster of esophageal intramural pseudodiverticula (Fig 1) (6).
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Figure 1. Peptic stricture with esophageal intramural pseudodiverticula. Double-contrast esophagogram shows a smooth, tapered area of concentric narrowing in the distal esophagus (large arrow) above a hiatal hernia. This is the classic appearance of a peptic stricture. Note also the tiny esophageal intramural pseudodiverticula in the region of the stricture (small arrows). Some of the pseudodiverticula seem to be "floating" outside the wall of the esophagus without direct communication with the lumen, a characteristic radiographic feature of these structures.
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Figure 2. Peptic stricture. Double-contrast esophagogram shows an eccentric area of narrowing in the distal esophagus (arrow), a finding that resulted from asymmetric scarring from reflux esophagitis.
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Figure 3. Peptic stricture with sacculations. Double-contrast esophagogram shows an eccentric area of narrowing in the distal esophagus (black arrow) above a hiatal hernia. Note the associated sacculations (white arrows) that resulted from outward ballooning of the esophageal wall between areas of fibrosis.
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Figure 4. Peptic stricture with fixed transverse folds. Double-contrast esophagogram shows a mild peptic stricture in the distal esophagus (white arrow) with barium collections between fixed transverse folds (black arrows), findings that produce a characteristic "stepladder" appearance. Note that the folds are wider than the delicate transverse striations in feline esophagus and do not extend more than halfway across the esophagus.
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Some patients may have a variant of a peptic stricture that is characterized by a very short segment of ringlike narrowing at the gastroesophageal junction above a hiatal hernia (Fig 5) (3,7). Such strictures may be mistaken for Schatzki rings; however, Schatzki rings usually appear as smooth, symmetric ringlike constrictions with abrupt borders and a length of only 1–3 mm (Fig 6) (8,9), whereas annular peptic strictures have more tapered borders and a length of over 4 mm (Fig 5) (7).
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Figure 5. Ringlike peptic stricture. Double-contrast esophagogram shows an area of ringlike narrowing in the distal esophagus (arrows) above a hiatal hernia. Note the resemblance to a Schatzki ring (cf Fig 6). However, this ringlike stricture is more asymmetric and has more tapered borders and a greater length than do most Schatzki rings.
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Figure 6. Schatzki ring. Prone single-contrast esophagogram shows a classic Schatzki ring (arrows), which appears as a smooth, symmetric, ringlike constriction at the gastroesophageal junction above a hiatal hernia. Note that the ring has a length of only 2 mm and has more abrupt borders than does a ringlike peptic stricture (cf Fig 5).
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Hiatal hernias are seen at barium examination in more than 90% of patients with peptic strictures (7,10), so that the possibility of malignant tumor should be considered when a distal esophageal stricture is detected in the absence of a hernia. Nevertheless, malignant strictures usually have more irregular and nodular contours and more abrupt or "shouldered" proximal and distal margins than do benign peptic strictures (Fig 7). As a result, it is usually possible to differentiate benign strictures from infiltrating carcinomas on the basis of the radiographic findings (7).
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Figure 7. Infiltrating esophageal carcinoma. Double-contrast esophagogram shows a malignant stricture with the typical features: a markedly irregular contour and abrupt, shelflike proximal and distal margins (arrows).
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Scleroderma
Scleroderma is a connective tissue disease characterized by smooth muscle atrophy and fibrosis in the esophageal wall. Affected individuals often have a patulous, incompetent lower esophageal sphincter with spontaneous gastroesophageal reflux as well as absent primary peristalsis in the esophagus below the level of the aortic arch. This abnormal motility results in poor clearance of peptic acid reflux from the esophagus. Consequently, affected patients frequently develop a severe form of reflux esophagitis, peptic strictures, and, eventually, Barrett esophagus. These strictures can be extremely narrow or long (Fig 8) and are sometimes associated with multiple sacculations caused by asymmetric ballooning of the esophageal wall between areas of fibrosis.
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Figure 8. Scleroderma with a peptic stricture. Double-contrast esophagogram shows a relatively long segment of tapered narrowing in the distal esophagus (arrows) that resulted from marked peptic scarring in a patient with esophageal involvement by scleroderma.
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Nasogastric Intubation
Nasogastric tubes prevent closure of the lower esophageal sphincter, resulting in continuous bathing of the distal esophagus with acid reflux from the stomach (11). Thus, nasogastric intubation may occasionally cause severe esophagitis and, rarely, the development of distal esophageal strictures whose length and severity increase rapidly over a short period of time (Fig 9) (12,13). Strictures most often develop after prolonged nasogastric intubation but occasionally after intubation for only 2–3 days (12).
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Figure 9. Nasogastric intubation stricture. Prone single-contrast esophagogram shows a relatively long segment of narrowing in the distal esophagus (arrows). This stricture developed 3 months after prolonged nasogastric intubation.
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Zollinger-Ellison Syndrome
Zollinger-Ellison syndrome can lead to the development of severe reflux esophagitis as a result of the increased acidity of peptic acid reflux in the esophagus rather than an increased frequency or duration of reflux episodes. Because of the severity of the esophagitis, affected individuals may develop unusually long strictures in the distal esophagus (14,15). Occasionally, patients with Zollinger-Ellison syndrome may even present with esophageal strictures as the initial manifestation of disease (14).
Alkaline Reflux Esophagitis
Patients who undergo partial or total gastrectomy may experience reflux of bile or pancreatic secretions into the esophagus, resulting in the development of severe alkaline reflux esophagitis and distal esophageal strictures whose length and severity increase rapidly over a short period of time (16,17). Such stricture formation can sometimes be avoided by performing Roux-en-Y reconstruction at the time of surgery to prevent reflux of bile or pancreatic secretions into the esophagus (17). An alkaline reflux stricture should be suspected when barium examination performed in patients who have undergone partial or total gastrectomy or gastrojejunostomy reveals a long stricture in the distal esophagus.
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Causes of Upper and Midesophageal Strictures
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Barrett Esophagus
Barrett esophagus is an acquired condition in which there is progressive columnar metaplasia of the distal esophagus as a result of chronic gastroesophageal reflux and reflux esophagitis (18). Because Barrett esophagus is a premalignant condition associated with an increased risk of developing esophageal adenocarcinoma, many investigators advocate endoscopic surveillance of patients with known Barrett esophagus to detect dysplastic or early carcinomatous changes before the development of overt carcinoma (18).
The majority of strictures in Barrett esophagus are typical peptic strictures in the distal esophagus (19,20). However, a small percentage of patients with Barrett esophagus develop strictures in the upper or midesophagus below the level of the aortic arch (19,20). In such cases, there is usually a long segment of columnar metaplasia, with the stricture occurring at an elevated squamocolumnar junction. These strictures typically appear as ringlike constrictions or, less commonly, as smooth, tapered segments of concentric narrowing in the midesophagus (Figs 10, 11) (20). In the presence of a hiatal hernia and reflux, a focal stricture in the midesophagus is highly suggestive of Barrett esophagus (4).
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Figure 10. Barrett esophagus with a midesophageal stricture and a reticular pattern. Double-contrast esophagogram shows a focal area of mild narrowing in the midesophagus (black arrow). Note also the distinctive reticular pattern that extends distally a considerable distance from the stricture (approximately to the level indicated by the white arrow). This reticular pattern is thought to result from intestinal metaplasia in Barrett mucosa. (Reprinted, with permission, from reference 20.)
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Figure 11. Barrett esophagus with a midesophageal stricture. Double-contrast esophagogram shows a relatively long segment of tapered narrowing in the midesophagus (arrows). A hiatal hernia and gastroesophageal reflux were seen at fluoroscopy.
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Double-contrast esophagography may occasionally reveal a reticular pattern of the mucosa that extends distally a variable distance from a midesophageal stricture, findings that represent another sign of Barrett esophagus (Fig 10) (21). The reticular pattern is characterized by a network of thin, linear or intersecting barium-filled grooves or crevices on the mucosa, producing a distinctive radiographic appearance. This pattern is thought to result from intestinal metaplasia, a form of Barrett mucosa associated with an even higher risk of malignant degeneration (21). Therefore, detection of a reticular pattern adjacent to the distal aspect of a midesophageal stricture at double-contrast esophagography should lead to early endoscopy and biopsy to confirm the presence of Barrett esophagus and rule out dysplasia or early carcinomatous changes.
Mediastinal Irradiation
Many patients who undergo irradiation of the mediastinum develop an acute, self-limited form of esophagitis. Patients who receive high doses of mediastinal radiation (usually 5,000 cGy or more) may develop progressive dysphagia 4–8 months after completion of radiation therapy because of the development of radiation-induced strictures (22,23). Certain chemotherapeutic agents such as adriamycin can potentiate the effects of radiation therapy, so that affected individuals may develop strictures with doses of mediastinal radiation as low as 500 cGy (24).
Radiation strictures typically appear at barium examination as smooth, relatively long segments of concentric, tapered narrowing within a preexisting radiation portal (Fig 12) (22,23). Most radiation strictures occur in the upper or midesophagus because of the location of the portal. When strictures are detected in patients who have undergone radiation therapy, the major consideration in the differential diagnosis is esophageal involvement by recurrent tumor in the mediastinum. However, recurrent tumor tends to manifest as more irregular narrowing, asymmetric mass effect, and ulceration. Consequently, it is usually possible to differentiate radiation strictures from recurrent tumor involving the esophagus on the basis of the radiographic findings.
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Figure 12. Radiation stricture. Double-contrast esophagogram shows a smooth, tapered segment of concentric narrowing in the midesophagus (arrows). The stricture was caused by prior mediastinal irradiation.
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Ingestion of Caustic Substances
Injury to the esophagus may be caused by ingestion of strong acids (eg, hydrochloric acid) or strong bases (eg, lye). Marked caustic esophagitis leads to stricture formation 1–3 months after the initial injury. Depending on the degree of injury and scar formation, affected patients may develop one or more segmental strictures that have an unpredictable location or, in severe cases, diffuse esophageal strictures that reduce the entire esophagus to a thin, filiform structure (Fig 13) (25),occasionally necessitating esophageal replacement surgery. Caustic injury to the esophagus is, therefore, associated with the most extensive stricture formation that occurs in the esophagus. Patients with chronic lye strictures also have a substantially increased risk of developing esophageal carcinoma (26).
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Figure 13. Caustic stricture. Double-contrast esophagogram shows a long stricture involving most of the thoracic esophagus. The stricture resulted from ingestion of a caustic substance many years earlier.
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Drug Ingestion
Although tetracycline and its derivative, doxycycline, are the two agents most commonly responsible for drug-induced esophagitis in the United States, they usually cause only superficial ulceration that heals without scarring or stricture formation. In contrast, drugs such as quinidine, potassium chloride, alendronate, and aspirin or other nonsteroidal anti-inflammatory agents may result in severe esophagitis with larger areas of ulceration and the development of strictures (27–29). The esophagitis typically results from prolonged irritation of the mucosa caused by pills that lodge in the esophagus at sites of extrinsic compression by adjacent structures such as the aortic arch, left main bronchus, or enlarged left chambers of the heart. The resulting strictures are usually located in the upper or midesophagus, appearing at barium examination as segmental areas of concentric narrowing (Fig 14). Rarely, however, these strictures may have a malignant appearance, necessitating endoscopy and biopsy to rule out esophageal carcinoma (30). Careful correlation with the patient’s drug history is critical in such cases.
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Figure 14. Drug-induced stricture in a patient who developed dysphagia 6 months after taking potassium chloride for hypokalemia. Double-contrast esophagogram shows a slightly asymmetric focal area of narrowing in the upper thoracic esophagus (arrow) above the level of the aortic arch.
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Congenital Esophageal Stenosis
A severe form of congenital esophageal stenosis occurs in newborns or infants and generally requires surgery. However, a milder form is occasionally encountered in young or even middle-aged adults, typically men with a lifelong history of mild, "compensated" dysphagia and recurrent food impactions (31). The stenotic segment may appear at barium examination as a focal stricture containing distinctive ringlike indentations, most commonly in the midesophagus ("ringed" esophagus) (Fig 15) (31). Some investigators believe that these ringlike indentations represent tracheobronchial remnants or cartilaginous rings in the wall of the esophagus (31). However, other authors argue that ringed esophagus is not a congenital condition but an acquired condition caused by gastroesophageal reflux disease (32). Whatever the explanation, this condition should be suspected when esophagography performed in the proper clinical setting demonstrates a midesophageal stricture containing multiple ringlike indentations.
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Figure 15. Congenital esophageal stenosis in a young man with long-standing dysphagia and occasional superimposed food impactions. Double-contrast esophagogram shows an area of mild narrowing in the midesophagus with distinctive ringlike indentations ("ringed esophagus") (arrows) in the region of the stricture. Endoscopic findings confirmed the presence of a mild stricture in the midesophagus with indentations that resembled tracheal rings.
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Skin Diseases
Upper or midesophageal strictures may occasionally be encountered in patients with skin diseases such as epidermolysis bullosa dystrophica, benign mucous membrane pemphigoid, and erythema multiforme major (33–36). Esophageal involvement by epidermolysis bullosa dystrophica and benign mucous membrane pemphigoid is characterized by bullae, ulcers, and, eventually, stricture formation. These strictures may appear at barium examination as one or more segments of concentric or asymmetric narrowing in the upper or midesophagus, sometimes with associated webs in this region (Fig 16) (33–35). Rarely, esophageal involvement by erythema multiforme major may also manifest as the development of long esophageal strictures (36). Such conditions can be differentiated from other, more common causes of esophageal strictures on the basis of a history of bullous skin disease in affected patients.
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Figure 16. Benign mucous membrane pemphigoid. Single-contrast esophagogram shows a focal stricture in the upper esophagus (arrow) near the thoracic inlet. The stricture resulted from esophageal involvement by benign mucous membrane pemphigoid. Other skin diseases such as epidermolysis bullosa dystrophica may produce similar strictures.
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Esophageal Intramural Pseudodiverticulosis
Esophageal intramural pseudodiverticula are dilated excretory ducts of the deep mucous glands in the esophagus. They typically appear at esophagography as multiple flask-shaped outpouchings or tiny collections of barium that appear to "float" outside the wall of the esophagus without direct communication with the lumen (Fig 1) (6,37). Some patients with this condition have associated strictures in the upper or midesophagus (Fig 17) (6,37). These strictures may be short or long, and, in most cases, no other cause can be found for their development. When such strictures are present, the pseudodiverticula usually extend a considerable distance above and below the level of the strictures (37). Other patients with esophageal intramural pseudodiverticulosis may have localized involvement of the distal esophagus in the region of a peptic stricture (Fig 1), so that the pseudodiverticula presumably develop as a sequela of scarring from reflux esophagitis (6).
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Figure 17. Esophageal intramural pseudodiverticulosis. Double-contrast esophagogram shows a moderately long stricture in the upper thoracic esophagus (straight solid arrows). Note the tiny esophageal intramural pseudodiverticula (curved solid arrows) at and below the level of the stricture. Note also the intramural tracking of barium between adjacent pseudodiverticula (open arrows). Despite the dramatic radiographic findings in such cases, a localized cluster of pseudodiverticula in the distal esophagus in the region of a peptic stricture is actually more common (cf Fig 1).
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Other Causes of Strictures
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Other unusual causes of stricture formation in the esophagus include Crohn disease (38,39), Candida esophagitis (40,41), graft-versus-host disease (42), eosinophilic esophagitis (43,44), Behçet disease (45), endoscopic sclerotherapy for esophageal varices (Fig 18) (46), and glutaraldehyde contamination at endoscopy (Fig 19) (47). In such cases, the correct diagnosis is often suggested by the clinical history.
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Figure 18. Esophageal stricture caused by endoscopic sclerotherapy. Single-contrast esophagogram shows a long, irregular stricture in the distal esophagus (straight white arrows) that resulted from scarring caused by prior endoscopic sclerotherapy for esophageal varices. Note also the flat ulcer in the region of the stricture (curved white arrow). Black arrows indicate a transjugular intrahepatic portosystemic shunt.
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Figure 19. Glutaraldehyde-induced stricture in a patient who developed dysphagia several months after undergoing endoscopy. Double-contrast esophagogram shows a long stricture that involves the middle and distal esophagus (arrows). There were no other predisposing factors for the development of this stricture, which was presumed to be caused by toxicity from residual glutaraldehyde at endoscopy.
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Barium Examination and Endoscopy for Evaluation of Strictures
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Esophagography has been found to have a sensitivity exceeding 95% for the detection of esophageal strictures (3,48,49). In the gastroenterology literature, some authors have argued that all radiographically diagnosed esophageal strictures should be evaluated with endoscopy and biopsy because of the difficulty of differentiating benign causes of luminal narrowing from malignant tumor on the basis of the radiographic findings alone (50–53). However, the recent radiology literature has shown that esophageal strictures with an unequivocally benign appearance at esophagography are almost never caused by malignant tumor (7). Therefore, early endoscopy and biopsy may be reserved for those strictures that have an equivocal or malignant radiographic appearance.
Despite the confidence that radiographically benign esophageal strictures are in fact benign, the evaluation of strictures at esophagography is complicated by the fact that the majority of benign strictures are caused by scarring from reflux esophagitis. These peptic strictures are associated with a high prevalence of Barrett esophagus, a premalignant condition that leads to the development of esophageal adenocarcinoma by means of progressively severe epithelial dysplasia (18). Affected patients may still require endoscopy and biopsy to confirm the presence of Barrett esophagus, assuming that they are candidates for endoscopic surveillance based on their age and overall medical condition. Not infrequently, however, peptic strictures contain areas of esophagitis and reactive changes that are difficult to differentiate from dysplasia in Barrett esophagus at endoscopic biopsy (54). Thus, an argument could be made for delaying endoscopy while these patients undergo a trial of medical therapy with antisecretory agents to heal the esophagitis and clarify the histologic diagnosis of Barrett esophagus. It has also been found that treatment of the underlying esophagitis may be as important as esophageal dilatation procedures for the relief of dysphagia (55), so that these procedures may be reserved for patients with persistent dysphagia after they have received medical treatment. Thus, the ability to differentiate benign peptic strictures from malignant tumor at barium examination has potential clinical benefit for these patients.
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Conclusions
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The clinical and radiographic findings associated with the various causes of stricture formation in the esophagus are summarized in the Table. When esophageal strictures are detected at barium examination, the underlying cause is usually suggested by the clinical history, the appearance and location of the strictures, and the presence of other associated radiographic findings. Therefore, radiologists have a major role, not only in detecting esophageal strictures, but also in determining their cause.
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Abstract
LEARNING OBJECTIVES
