Oesophageal Stricture Health Implication: The Story Of Chief Mr. Olivier Chukwuemeka From Enugu, Nigeria
Igbo Chief In Nigeria
Chief, Dr. Olivier Chukwuemeka's Story
Chief Dr. Olivier is from the Eastern Part of Nigeria. 49 years of age and an established business Man who specializes in imports and exports. Due to his busy activities, Chief Olivier seems to be well acquainted with his health and was able to detect Oesophageal signs after mistakenly taking in some Chemicals mixed with his drink in one of his workshop. He has done well to manage the syndrome for some weeks now, then one day something happened.
He felt so weak and was almost unable to move. He managed to check his Blood pressure which was 75/60 mmHg (Very low and bad). He began to feel pain just behind his breastbone and he had this characteristic feeling of fear. His skin was pale and covered with cold sweat. He could feel his heart beat happening in a faster tone. On trying to figure out what the problem might be, he fainted.
He was rushed to the Hospital and after a series of diagnostic evaluations, he was diagnosed withAcute Severe, Oesophageal Stricture of III degree.
Goodness! Is this a fatal situation? Let's find out!
Pathology & Classification
There are other disease processes which can produce Oesophageal strictures.
- Intrinsic diseases which reduce or narrow the Lumen (opening) of the Oesophagus via fibrosis, inflammation or neoplasia.
- Extrinsic diseases affecting the Lumen of the Oesophagus by direct invasion or enlargement of Lymph node.
- DIseases which cause disorders of Oesophageal peristalsis and/or lower Oesophageal Sphincter function.
Other causes could be autoimmune diseases, congenital anomalies, infections, Drug-induced and malignancy.
Oesophageal stricture occurs due to gastroesophageal reflux- induced Esophagitis. There are four stages to this pathologic development.
- The stage of acute Oesophagitis which lasts for 1-2 months and is characterized by Edema (accumulation of fluid) and propagation of dead tissues (necrosis). This stage is harzadous for erosive bleeding.
- The stage of chronic Esophagitis which is characterized by Ulcers of different sizes with granulating (newly forming) tissues at their bases as healing process begins. Focal constrictions of Oesophageal lumen are formed.
- The stage of cicatrical strictures (scar formation) of Oesophagus which begins from 2nd to 4th month and lasts to 2 years.
- The stage of late complications. It forms in 2 years after the burn and is characterized by advanced scar stricture of Oesophagus.
In view of this stages, we can then have various degrees of this ailment.
- I degree: Superficial burn with the damage of epithelial layer of Esophagus
- II degree: The burn with the damage of entire musoca of Oesophagus.
- III degree: The burn damage of all layers of Oesophagus.
- IV degree: The spread of post burn necrosis on para-Esophageal tissue and adjacent Organs.
What Is Oesophageal Stricture?
It is the narrowing of the Oesophagus or Oesophageal lumen which makes it difficult for swallowing. This can be due to thermal and radial burns, or as a result of Esophagitis or peptic Ulcers. But the most frequent cause of this ailment has always been Chemical burns, just as is the case with Chief Mr. Chukwuemeka. Most cases of attempted suicide through drinking poison are presented with Oesophageal strictures when arrested in time.
Acute period (Mild)
- Moderate pain at swallowing which sometimes can cause salivation and hoarseness.
- Oesophageal peristalsis is maintained.
- Normally, the clinical manifestation of the burn disappears in 5-7 days.
- Acute substernal (behind the breastbone) and pharyngeal pain during swallowing.
- Repeated vomiting, feeling of fear and excitement.
- Increased heart rate (Tachycardia)- 120- 130 beats/min.
- Body temperature rises to 39 0C
- Frequent Oliguria (low output of Urine within 300ml to 500ml of Urine excretion per day).
- Signs of shock (weak pulse), just as in the case of Chief Chukwuemeka
- Expressed Tachycardia (Increase in Heart rate).
- Acute substernal pain, further weakness and the feeling of fear.
- Pale skin covered with cold sweat.
- Worsened by Oliguria (reduce Urine output) which can transit into Anuria (Literaly means no urine excretion at all, but practically speaking, it is excretion of urine less than 50ml in a day).
In this period, the Oesophageal wall begins to heal and so, dead tissues (necrotic tissues) are replaced with new growing ones (granulations), as general condition of the patient improves. Acute signs as well disappear and patient begins to swallow freely, without the feeling of discomfort. At the end of this period, the healing process is summed up with the formation of scar on the wounds (areas of burns). Hence the next period of the disease.
Period of Scar formation
- It lasts for 1 to 12 months
- The newly grown tissues (granulations) are replaced by scar tissues.
- This scar tissues are not the normal or natural tissues of the Oesophagus, hence result to stricture and disturbance of swallowing of firstly, solid foods, then liquid ones.
- Such strictures develop at the Orifice (Opening) of the Oesophagus, in projection of Tracheal bifurcation and in the place of gastroesophageal junction. The passage of food through the constricted regions of Oesophagus is possible at fist only due to careful grinding and watering, but further it is inefficient. Thereafter, food delay in Oesophagus, choking, salivation, belching and vomiting develops. If the stricture is located in the lower part of the Oesophagus, the vomits can be of putrefactive character (vomits accompanied by foul offensive smell). Progressive weight loss observed, which can transit into Cachexia (wasting syndrome which consists of loss of weight, muscle atrophy, fatigue, weakness, and significant loss of appetite) without correction.
Presence Of Food Bolus In stricture
More About the Disease
- Lesions caused by chemical burns, corrosive substance intake, such as household cleaning agents, thermal burns and radial burns.
- Lesions caused by irritation of the Oesophagus by medications (antibiotics and such used to treat Osteoporosis)
- Malignancy of the Oesophagus: Oesophageal cancer
- Enlarged veins in the Oesophagus (Oesophageal varices)
- Lesions caused by administration of endoscope (a thin, lighted tube used to view the interior of internal organs).
- Prolonged usage of nasogastric tube ( a tube inserted through the nose to the stomach for clinical investigations).
- Chronic Heart burn, known as gastroesophageal reflux disease (GERD).
1. Disturbance of Valvular function of Epiglottis: The Epiglottis is a piece of muscle which functions to avoid food substances pass across from the Oesophagus to the Trachea. But when Oesophageal stricture persists, it can alter its physiology, through salivation causing the aspiration of fluid into the trachea (which is meant for breathing and air passage), infection of the airways results and then development of bronchitis and Pneumonia.
2. In about 25% of patients, Oesophageal burns are combined with gastric burns, mainly of its pyloric part.
3. Gastrointestinal bleeding
4. Perforation of the stomach
5. Mediastinitis: Mostly in deep burns of III and IV degree, the Oesophagus is perforated or a spread of infection into the mediastinum either through blood or lymphatic system occurs. Clinical manifestation in this case is the septic state and severe intoxication of the patient.
7. Difficulty in respiration
8. On X-ray: The distention of the mediastinal shadow, sometimes detached mediastinal pleura.
10. Pericarditis and Lung abscess.
1. X-ray examination of Oesophagus and Stomach by barium swallow. In this situation, the patient will swallow barium and X-rays can be taken to show the narrowing of the Oesophagus.
2. Endoscopic examination of Oesophagus, stomach and duodenum. Here, a narrow tube is inserted into the Oesophagus and it is connected to a screen of which it shows any narrowing of the Oesophageal wall.
3. In the mild stage of the acute manifestation of this illness, the Lumen of the Oesophagus is without changes and with free passage of Barium during Barium examination on X-ray. In Moderate severity, the Oesophagus is dilated but in some places can be constricted as the result of edema or spasm. But during its severe form, Barium swallow even becomes problematic.
4. As for Endoscopic revelations: Oesophageal peristalsis is maintained in mild severity. But the Lumen is filled with considerable amount of slime in moderate severity. Furthermore, the contours of the mucosal folds are irregular, the peristalsis is weakened or absent at all. If there will be no complication, in 10-15 days, the clinical manifestation of the disease disappears and general state of the patient is improved. In its severe form, expressed manifestation of Oesophagitis is seen, the Oesophagus is dilated and mucosal folds are difficult to reveal. Peristalsis is absent (complete atony).
- Pylorostenosis: This has similar symptoms with Oesophageal stricture but endoscopic investigation of the Oesophagus and stomach will distinguish their differences.
- Oesophageal Cancer: Also similar, especially in X-ray picture but histological investigation of the biopsy material obtained during endoscopy is suffificent to distinguish.
Oesophageal Dilatation Tubes
Drink a lot of Water to Cleanse The Oesophagus
The main principle of treatment is to avoid the development of Oesophageal strictures in the first place; hence fist aid must be administered as soon as possible after taking of chemical substance by means of gastric tube application and great amount of water (10-15 Liters) to immediately wash out the Oesophagus and stomach.
If the burn is caused by acid, 2% solution of Sodium hydrocarbonate is applied and in alkaline burns- Vinegar in the ratio 1:20 with water is applied. Anesthesia can be applied to reduce shock and psycho-emotional excitement from the patient.
In some cases, edema of the Pharynx and epiglottis can result to asphyxia; hence tracheostomy is performed.
In cases of shock and hypovolemia; massive intravenous infusions (up to 4-5 Liters per day) of saline solutions of glucose, dextrous and blood plasma are administered and for detoxication, forced diuresis is applied.
Use anti-bacterial therapy against any form of infection.
In the first two days, after the burn, the patients gets parenteral feeding. Nevertheless, if the swallowing is not disturbed, it is possible to add feeding by grinding cold food. The early application of enteric feeding can serve as a dilating medium for the Oesophagus and a simultaneous prophylaxis of scar strictures.
In the third period of the disease, scar formation is most likely to occur. Hence dilatation is carried out by a special elastic thermolabile bougies. This procedure prevents perforation of Oesophagus.
In advanced cases where even the bougienage may not help, Surgery becomes the final option. Esophagoplasty by stomach, small and large intestine is applied.
Please, try to avoid any form of corrosive or poison intake!
© 2014 Funom Theophilus Makama