A sour-ry state of the oesophagus – Pseudo-corrosive stricture

A 12-year-old girl presented with complaints of epigastric pain and dysphagia since six months, for which she was treated with nonsteroidal anti-inflammatory drugs (NSAID). On inquiry, the patient gave a history of poor dietary habits with excessive tamarind consumption for the past two years. On examination, the patient appeared pale and emaciated.

An oesophagogram showed a long segment with significant narrowing involving the thoracic oesophagus (supra-aortic, aortic and infra-aortic retro-cardiac segments) with reduced distensibility (Figures 1a and 1b). There was delayed passage of the contrast medium from the prestenotic area, but with subsequent complete passage, into the stomach. There was no mucosal irregularity. Previous oesophagograms, five (Figures 2a and 2b) and two months back (Figures 3a and 3b), showed a short segment stricture involving the distal oesophagus (epiphrenic segment) with mucosal irregularities suggestive of inflammation. There was progression of the stricture with near complete involvement of the entire thoracic oesophagus at present. There was no hiatus hernia.

The patient underwent an upper gastrointestinal (GI) endoscopy twice, after the first and second oesophagograms, along with dilatation. The endoscopy showed multiple ulcers in the post-cricoid area along with circumferential ulcerations 25 cm from the incisors.

An oesophageal stricture is one of the common causes of dysphagia. Common causes of dysphagia in children include gastroesophageal reflux and eosinophilic oesophagitis [1]. Dysphagia in paediatric populations can have a detrimental effect on dietary intake and, thus, can lead to failure to thrive, and aspiration pneumonias. They simply cannot maintain a good diet [2]. As a result, it is imperative to accurately identify and appropriately manage dysphagia in paediatric populations.

Oesophagograms are a readily available radiological investigation to screen for an oesophageal stricture. When oesophageal strictures are detected on 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 [3].

Children are more likely to ingest corrosive substances either accidentally or out of curiosity [2]. Corrosive stricture typically appears as long areas of smooth tapered narrowing, typically involving the cervical or upper thoracic oesophagus. They may also have irregular contours or eccentric areas of sacculation due to asymmetric scarring of the oesophagus. In severe cases, thread-like/filiform appearance of the entire thoracic oesophagus has been observed due to severe scarring.

Peptic stricture appears as short segment, smooth, tapered areas of concentric narrowing, typically in the distal oesophagus. They may be associated with axial hiatus hernias. Sometimes due to reflux, asymmetric appearances have been observed with puckering deformity or sacculations of one wall of the stricture [4].

In our case, an initial diagnosis of corrosive stricture was made on the basis of the patient’s age, upper GI endoscopy, and the characteristic long segment involvement on an oesophagogram. The review of the previous oesophagograms confirmed the diagnosis of a peptic stricture in view of a clinical history of epigastric burning and pain with insidious onset and progression of symptoms (no symptoms of acute corrosive poisoning). There was a radiological progression from a distal oesophageal stricture to near complete oesophageal stricture.

The dietary history of excessive consumption of tamarinds and concomitant use of NSAIDs were risk factors for peptic ulcer disease in this patient. Tamarind (Tamarindus indica), a commonly used spice, is acidic in nature and has been shown to be associated with peptic ulcers when consumed in larger quantities.

The patient was treated with multiple dilatations and diet modification.