From the Guidelines
No, a CT scan is not mandatory for every patient with an esophageal stricture found on endoscopy, but it should be considered in cases where biopsies are negative, but clinical or endoscopic features are atypical or suspicious for malignancy. The decision to perform a CT scan should be based on clinical suspicion of malignancy, which depends on several factors, including progressive dysphagia, significant weight loss, advanced age, smoking history, alcohol use, or suspicious endoscopic findings 1. According to the UK guidelines on oesophageal dilatation in clinical practice, biopsies should be taken during endoscopy from any suspicious areas to exclude malignancy and eosinophilic oesophagitis 1.
Key Considerations
- Patients with concerning features such as irregular, asymmetric, or ulcerated strictures should undergo CT scanning to evaluate for malignancy and assess for local invasion or metastatic disease.
- Biopsies should be taken during endoscopy from any suspicious areas, as this provides the definitive diagnosis.
- For patients with benign-appearing strictures, especially those with clear etiology like reflux disease, eosinophilic esophagitis, or caustic injury, and without alarm symptoms, CT scanning may not be necessary.
- The rationale for selective CT use is to avoid unnecessary radiation exposure and healthcare costs while ensuring that potentially malignant conditions are not missed.
Clinical Approach
In cases where the clinical picture is unclear, it is safer to proceed with CT imaging to rule out malignancy, as recommended by the guidelines 1. This approach prioritizes the detection of malignancy, which is crucial for determining the appropriate treatment and improving patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Diagnosis of Malignancy in Oesophageal Stricture
- The need for a CT scan to diagnose malignancy after seeing an oesophageal stricture on endoscopy is not absolute and depends on various factors, including the appearance of the stricture and the patient's clinical presentation 2.
- Endoscopic ultrasound (EUS) can be a useful diagnostic tool in patients with esophageal strictures and negative biopsies, especially in those with suspicious endoscopic or radiographic appearance, atypical presentation, or failure to respond to treatment 2.
- Barium studies can also be helpful in differentiating between benign and malignant strictures, with radiographically benign strictures unlikely to be caused by malignant tumors 3.
Management of Oesophageal Strictures
- The management of oesophageal strictures depends on whether they are benign or malignant, with different treatment approaches for each type 4, 5.
- Endoscopic dilation, injectional therapy, stenting, stricturotomy, and ablation are some of the options available for treating oesophageal strictures, with the choice of treatment depending on the stricture's characteristics and the patient's condition 4, 6, 5.
- In cases of refractory or recurrent benign strictures, alternative approaches such as steroid injections, incisional therapy, and temporary stent placement may be considered 6, 5.
Role of CT Scan in Diagnosis
- While CT scans can be useful in suggesting the possibility of a tumor, they are not always necessary for diagnosing malignancy in patients with oesophageal strictures, especially if other diagnostic tools such as EUS or barium studies are available 2, 3.
- The decision to perform a CT scan should be based on the individual patient's clinical presentation and the results of other diagnostic tests, rather than being a routine part of the diagnostic workup for all patients with oesophageal strictures 2, 3.