Esophageal Stricture

How an esophageal stricture forms

The normal esophagus is about 2 cm (0.8 inches) wide and stretches as food passes. Repeated injury and healing produce scar tissue (fibrosis) that contracts and narrows the channel. Symptoms usually appear when the opening falls below about 13 mm. A stricture can be short and smooth (simple) or long, tight or twisted (complex), which are harder to treat.

Causes

Benign causes

• Peptic stricture from acid reflux: the most common cause. Years of gastroesophageal reflux disease and esophagitis scar the lower esophagus. Less common now that acid-suppressing medicines are widely used.
• Eosinophilic esophagitis (EoE): allergic inflammation causing rings and narrowing, often in young men with allergies; food impaction is a common first sign.
• Schatzki ring: a thin ring at the lower esophagus causing intermittent sticking.
• Radiation therapy to the chest or neck.
• Caustic ingestion: swallowing strong acids or alkalis such as drain cleaner causes severe, long strictures.
• Pill esophagitis: tablets such as doxycycline, potassium chloride, NSAIDs and some osteoporosis medicines can injure the lining if swallowed without enough water.
• Surgery: narrowing at a surgical join after esophagectomy or other operations.
• Prolonged nasogastric tube use.
• Skin and autoimmune diseases: lichen planus, epidermolysis bullosa, scleroderma.

Malignant causes

Esophageal cancer can cause progressive narrowing, typically with weight loss. Adenocarcinoma is linked to reflux and Barrett's esophagus; squamous cell carcinoma to smoking and alcohol.

Symptoms

• difficulty swallowing solids (dysphagia), often meat, bread or pills
• a sensation of food sticking behind the breastbone
• needing to chew carefully, eat slowly or drink to wash food down
• regurgitation of undigested food
• heartburn (with peptic strictures; heartburn may paradoxically ease as the stricture forms a barrier)
• weight loss if eating becomes difficult
• episodes of food impaction

Difficulty with liquids usually only occurs with very tight strictures.

Diagnosis

1. Upper endoscopy (EGD): the key test. A camera shows the stricture, and biopsies are taken to exclude cancer and check for eosinophilic esophagitis. Dilation can be done in the same session.
2. Barium swallow (esophagram): x-rays after drinking contrast liquid show the length, location and diameter of the stricture. Useful before endoscopy for complex strictures.
3. CT scan: if cancer or external compression is suspected.
4. Esophageal manometry: if a motility disorder such as achalasia is possible.

Treatment

Endoscopic dilation

The stricture is stretched under sedation during endoscopy using:

• Balloon dilators: inflated within the stricture.
• Bougie dilators: tapered tubes passed through the narrowing.

Dilation is usually done gradually, increasing the diameter over one or several sessions. Most people swallow much better immediately. Some strictures need repeated dilations over months or years.

Treat the cause

• Proton pump inhibitors (PPIs): for peptic strictures; long-term PPI use reduces the need for repeat dilation.
• Eosinophilic esophagitis: PPIs, swallowed steroids, elimination diets or dupilumab.
• Pill injury: take pills with a full glass of water, sitting upright.

Difficult (refractory) strictures

• steroid injections into the stricture before dilation
• incisional therapy (cutting the scar)
• temporary removable stents
• patient self-dilation in selected cases
• surgery, rarely

Malignant strictures

Treatment depends on cancer stage: surgery, chemotherapy, radiation, or stents to relieve swallowing.

Complications

• food impaction
• aspiration of regurgitated food, causing pneumonia
• weight loss and malnutrition
• risks of dilation: perforation (uncommon, around 1 in 1,000 or fewer for simple strictures), bleeding

Living with an esophageal stricture

• cut food into small pieces and chew thoroughly
• eat slowly and sit upright
• take sips of water between bites
• avoid dry, tough foods if they stick
• follow reflux advice: avoid late meals, raise the head of the bed, lose excess weight, stop smoking

Frequently asked questions

What causes an esophageal stricture?

The most common cause is long-term acid reflux scarring the lower esophagus. Other causes include eosinophilic esophagitis, radiation, swallowing caustic chemicals, pill injury, previous surgery and, less often, esophageal cancer.

What are the symptoms of an esophageal stricture?

The main symptom is difficulty swallowing solid food, with a feeling of food sticking in the chest that slowly worsens. Others include regurgitation, heartburn, needing to drink to wash food down and weight loss.

How is an esophageal stricture treated?

Most are treated by stretching the narrowed area during an endoscopy (dilation), using a balloon or tapered tubes. Acid-suppressing medicines help prevent recurrence of reflux strictures. Difficult strictures may need repeated dilations, injections or stents.

Is esophageal dilation painful?

It is done under sedation, so most people feel little or nothing. Mild chest discomfort or a sore throat afterward is common and settles within a day. Severe chest pain, fever or difficulty breathing after dilation needs urgent care.

Can an esophageal stricture come back?

Yes. Benign strictures can recur, especially if the underlying cause continues. Taking acid-suppressing medicine for reflux strictures and treating eosinophilic esophagitis reduce recurrence. Some people need periodic dilations.