Esophageal Strictures — Causes and Endoscopic Treatment

What Are Esophageal Strictures?

Esophageal strictures are abnormal narrowings of the esophagus (the muscular tube that carries food from the throat to the stomach). These narrowings restrict the passage of food and liquids, causing difficulty swallowing and a range of other symptoms. Esophageal strictures can be benign or malignant, and the distinction is critical for determining the appropriate treatment approach.

Causes

Benign Esophageal Strictures

• Peptic strictures — the most common type, caused by chronic gastroesophageal reflux disease (GERD). Repeated exposure to stomach acid causes inflammation, scarring, and narrowing, typically in the lower esophagus.
• Caustic ingestion — accidental or intentional ingestion of corrosive substances (acids or alkalis) can cause severe esophageal injury and subsequent stricture formation
• Radiation-induced — fibrosis following radiation therapy for cancers of the chest (lung, breast, lymphoma)
• Post-surgical (anastomotic) — strictures at surgical connection sites, commonly after esophagectomy or bariatric surgery
• Eosinophilic esophagitis (EoE) — a chronic allergic condition causing concentric rings and strictures in the esophagus
• Medication-induced (pill esophagitis) — caused by certain medications lodging in the esophagus
• Post-endoscopic — after extensive endoscopic resection (EMR, ESD) of esophageal lesions

Malignant Esophageal Strictures

• Esophageal cancer — squamous cell carcinoma or adenocarcinoma
• Gastric cancer — invasion of the gastroesophageal junction
• Extrinsic compression — lung cancer, mediastinal tumors, or lymphadenopathy compressing the esophagus

Symptoms

• Dysphagia — difficulty swallowing, initially with solid foods and progressing to liquids as the stricture worsens. This is the hallmark symptom.
• Odynophagia — painful swallowing, more common with active inflammation or malignant strictures
• Food impaction — food getting stuck in the esophagus, sometimes requiring emergency endoscopic removal
• Chest pain — a sensation of pressure or discomfort behind the breastbone during swallowing
• Unintentional weight loss — due to reduced food intake, particularly concerning for malignancy
• Regurgitation — undigested food returning to the throat
• Heartburn — especially with peptic strictures
• Aspiration symptoms — coughing, choking, or recurrent pneumonia from food or liquid entering the airway

Diagnosis

• Upper endoscopy (EGD) — the primary diagnostic tool. Diagnostic endoscopy allows direct visualization of the stricture, assessment of its severity, and tissue biopsy to distinguish benign from malignant strictures.
• Barium swallow — a contrast X-ray study that outlines the esophagus, useful for characterizing stricture length, location, and diameter
• CT scan — for suspected malignant strictures, to evaluate tumor extent and staging
• Endoscopic Ultrasound (EUS) — EUS can assess the depth of involvement and identify submucosal lesions

Treatment

Endoscopic Dilation

Endoscopic dilation is the mainstay of treatment for benign esophageal strictures and is performed during therapeutic endoscopy:

• Bougie dilation — tapered dilators are passed over a guidewire through the stricture, gradually stretching it
• Balloon dilation — a deflated balloon is positioned within the stricture and inflated to a controlled diameter
• Dilation is typically performed in a gradual, stepwise manner (the "rule of three") to minimize the risk of perforation
• Multiple sessions may be needed, particularly for complex or refractory strictures

Stenting for Malignant Strictures

For malignant esophageal strictures, self-expanding metal stents (SEMS) provide effective palliation by restoring the ability to swallow. Digestive stenting can rapidly improve quality of life for patients with inoperable esophageal or gastric cancers.

Additional Treatments

• Steroid injection — intralesional triamcinolone injection during dilation may reduce recurrence in refractory benign strictures
• Temporary stenting — fully covered removable stents for refractory benign strictures
• Incisional therapy — endoscopic electrocautery incision of fibrotic rings
• Acid suppression — high-dose proton pump inhibitors for peptic strictures to treat the underlying GERD

Diet After Dilation

• Clear liquids for the first few hours after the procedure
• Soft foods for 24-48 hours, then gradual advancement to a regular diet
• Chew food thoroughly and eat slowly
• Avoid large pieces of meat, bread, and other foods that tend to stick
• Sit upright during meals and for 30 minutes afterward
• Stay well hydrated between meals

Follow-Up Schedule

• Repeat dilation sessions are typically scheduled every 2-4 weeks until the target diameter is achieved (usually 15-18 mm)
• Long-term proton pump inhibitor therapy for peptic strictures
• Surveillance endoscopy to monitor for recurrence
• For malignant stents: follow-up to assess stent function, with re-intervention for stent migration or tumor ingrowth/overgrowth

When to Seek Medical Attention

• Complete inability to swallow, including saliva
• Food impaction that does not resolve within a few hours
• Severe chest pain after dilation or stent placement
• Fever after an esophageal procedure
• Progressive worsening of swallowing difficulty
• Signs of aspiration (coughing when eating, recurrent respiratory infections)
• Unintentional weight loss with swallowing difficulties