1. Vradelis, Stergios PhD, MD
  2. Doulberis, Michael MD
  3. Dellaporta, Erminia MD
  4. Babali, Asimenia PhD, MD
  5. Panagopoulos, Periklis PhD, MD
  6. Efraimidou, Eleni PhD, MD
  7. Kouklakis, Georgios PhD, MD

Article Content

Esophageal stricture represents a relatively frequent problem in gastroenterology practice. The most typical symptom upon presentation is dysphagia (Pregun, Hritz, Tulassay, & Herszenyi, 2009). The etiology of the esophageal stenosis could be either of benign or malignant origin. Peptic strictures as a result of end stage chronic reflux esophagitis are by far the most common benign cause (Ferguson, 2005; Pregun et al., 2009), which accounts for more than 75% of the cases, followed by pathologies such as Schatzki's rings, corrosive strictures (including medications), beam radiation, sclerotherapy, and infectious esophagitis (Ferguson, 2005). Malignant causes of esophageal strictures consist primarily of cancers (squamous cell carcinoma and adenocarcinoma) (Ferguson, 2005). The differential diagnosis among the previous categories in a patient with dysphagia can determine prognosis, but it can occasionally become controversial and strikingly challenging.


Case Report

An 85-year-old female patient with esophageal cancer was admitted to the hospital to replace her malfunctioning gastrostomy tube with a jejunostomy tube. She was "diagnosed" with esophageal cancer 3 years ago. She initially presented to a gastroenterologist in private practice complaining of dysphagia. Upper gastrointestinal endoscopy revealed an esophageal stricture approximately 23 cm from the dental barrier, the mucosa of which was friable and bled easily. The consultant hypothesized esophageal malignancy and several biopsy samples were obtained from suspicious lesions.


Two days later, an esophagography was performed where significant grade of stenosis at the level of the carina was observed with concomitant loss of clarity of the esophageal wall. These findings were compatible with the presence of an infiltrating neoplastic mass and thoracic computed tomographic (CT) scan was suggested. The CT scan indicated thickening of the esophagus at the level of the carina, with accompanying narrowing of the esophageal lumen (Figure 1) at the gastroesophageal junction as well as enlarged paratracheal and precarinal lymph nodes. Prestenotic esophageal distension could also be recognized (Figure 2). These findings were also suggestive of an esophageal malignancy. However, histopathologic examination depicted only inflammatory granulation tissue, with foci of necrosis, abscessation, and variably sized clefts. Given the fact that the untreated-for-cancer patient was still alive 3 years later and there was no definite histopathologic proof of malignancy, the prior diagnosis of cancer was questioned. Thus, after written informed consent from the patient had been obtained, another upper gastrointestinal endoscopy was performed where the region of stricture was identified and characterized as peptic stricture.


New multiple biopsy specimens were taken from stenotic mucosa, all of which were found to be histologically negative for malignancy. Then dilation of the esophagus was attempted (CRE, wire-guided balloon Dilator, 10-12 mm; Boston Scientific, Boston, MA), which was successful. Two weeks later, a second dilation session was implemented and a fully covered self-expandable esophageal metal stent (Wallflex, 18 mm x 103 mm, Boston Scientific) was placed in the distal esophagus. The patient is still alive and, after 3 years of feeding via a gastrostomy/jejunostomy tube, is capable again of feeding per mouth.

Figure 1 - Click to enlarge in new windowFIGURE 1. Computed tomographic scan where thickening of the esophageal wall and elimination of lumen can be observed, after administration of oral contrast agent.
Figure 2 - Click to enlarge in new windowFIGURE 2. Computed tomographic scan of the same patient. A significant prestenotic distension of esophagus is visible.


Esophageal stricture is a well-documented gastrointestinal complication of several pathologies, which downgrades substantially the quality of life of patients. Early and proper diagnosis is mandatory for suitable regimen treatment. Nevertheless, there have been reported certain cases where differentiation from malignancy was tricky, yet prognosis diverged significantly.


Kurihara, Mizuseki, Ichikawa, Okada, and Miyata (2001) reported a case of a 54-year-old man who complained of dysphagia and was found to have a prominent stricture in the proximal esophagus. A subtotal esophagectomy was performed because of a biopsy that was indicative of sarcoma. Further histopathologic examination of the excised esophagus revealed that it was a benign inflammatory pseudotumor.


Wolf et al. (1988) reported three cases of benign lesions which mimicked malignant tumors of the esophagus. Two of them were inflammatory pseudotumors and one a diffuse leiomyomatosis, the clinical presentations, radiologic features, and gross pathologic findings of which led to the mistaken diagnosis of carcinoma at thoracotomy. The benign nature of these cases was recognizable only on microscopic examination.


In another recent paper (Weston, Thosani, Bektas, Oruc, & Bhutani, 2010), a 79-year-old male patient who presented with progressive dysphagia and had endoscopic and ultrasound findings compatible to esophageal cancer was found to have esophageal stricture due to pill esophagitis. Dysphagia that emerges from pill consumption is often gradual and patients fail to associate their symptoms with medication since acute pain is absent. Bisphosphonate pills are well known for causing esophageal strictures (Paul & Seetharaman, 2011; Wysowski, 2009) and in our patient, there was a history of long-term usage of alendronate. So, it is plausible to attribute her pathology to medication, although a pre-existing and nondiagnosed reflux esophagitis cannot be ruled out.



In conclusion, esophageal strictures constitute a common situation that gastroenterologists confront in daily medical practice, but diagnosis can eventually become difficult and with pitfalls. Imaging and other diagnostic methods are useful for the establishment of the benign or malignant origin of an esophageal stricture. Pathology also plays a critical role in determining whether the lesion is benign or malignant.




Ferguson D. D. (2005). Evaluation and management of benign esophageal strictures. Diseases of the Esophagus, 18(6), 359-364. [Context Link]


Kurihara K., Mizuseki K., Ichikawa M., Okada K., Miyata Y. (2001). Esophageal inflammatory pseudotumor mimicking malignancy. Internal Medicine, 40(1), 18-22. [Context Link]


Paul A. K., Seetharaman M. (2011). Esophageal stricture associated with alendronate use. Canadian Medical Association Journal, 183(7), E429. [Context Link]


Pregun I., Hritz I., Tulassay Z., Herszenyi L. (2009). Peptic esophageal stricture: Medical treatment. Digestive Diseases, 27(1), 31-37. [Context Link]


Weston B. R., Thosani N., Bektas M., Oruc N., Bhutani M. S. (2010). Pill esophagitis masquerading as esophageal cancer on endoscopy and endoscopic ultrasound. Visible Human Ournal of Endoscopy, 9(2), 9-11. [Context Link]


Wolf B. C., Khettry U., Leonardi H. K., Neptune W. B., Bhattacharyya A. K., Legg M. A. (1988). Benign lesions mimicking malignant tumors of the esophagus. Human Pathology, 19(2), 148-154. [Context Link]


Wysowski D. K. (2009). Reports of esophageal cancer with oral bisphosphonate use. The New England Journal of Medicine, 360(1), 89-90. [Context Link]