Esophageal Stricture

What is Esophageal Stricture?

An esophageal stricture is a condition where the esophagus (the tube that carries food from the mouth to the stomach) becomes abnormally narrow. This often causes trouble in swallowing, a symptom commonly referred to as dysphagia. This problem can be a serious result of a variety of illnesses and underlying causes, and it’s important to recognize and manage it quickly.

The narrowing of the esophagus, or stricture, can occur due to inflammation, scarring (fibrosis), or cancer (neoplasia) affecting the esophagus. These issues can potentially damage the inner lining (mucosa) and the layer beneath it (submucosa). When affected by a stricture, the esophagus can become less stretchy and the narrowing can affect just a particular area or the entire length of the esophagus. The narrowed section may have sudden or gradual edges.

Recent advancements in endoscopy, a procedure that helps diagnose or treat conditions with an instrument inserted through the mouth, have led to an increase in esophageal strictures caused by injury to the mucosa during the procedure.

Usually, the term ‘esophageal stricture’ refers to conditions within the esophagus that cause narrowing. However, external pressure, possibly from cancer or swollen lymph nodes, can also narrow the esophagus and produce a stricture. Nonetheless, regardless of the underlying cause, it’s vital to manage the condition quickly and aggressively to increase the size of the esophagus opening, which improves symptoms or provides relief in case of cancer.

Thanks to new technological advancements, therapies using endoscopes and different stent products (devices used to keep the esophagus open) have shown encouraging results, with noticeable improvements in managing the narrowing, low rates of the condition returning, and fewer complications.

What Causes Esophageal Stricture?

A stricture, or narrowing of the esophagus, can be either non-cancerous (benign) or cancerous (malignant). The best approach to handling a stricture is to identify why it happened. Most esophageal strictures arise from long-term acid reflux, also known as gastroesophageal reflux disease (GERD), accounting for 70 to 80% of cases in adults. Thankfully, the use of medication called proton pump inhibitors, which reduces the acid in the stomach, has lowered the occurrence of these types of strictures.

Besides long-standing acid reflux, other things can cause esophageal strictures. In young children and teenagers, swallowing corrosive substances, like household cleaning products, is the main cause of esophageal strictures. Here are some common and less common causes:

Non-Cancerous Strictures

Swallowed corrosive substances: While it may be accidental or intentional, swallowing household cleaners is not unusual. They can cause mild damage to full-thickness necrosis (death) of the esophagus. A stricture is a typical result of swallowing these toxic substances.

Eosinophilic esophagitis: This is a chronic illness where the immune system inflames the esophagus. It is becoming more prevalent and, because patients often go a long time without a diagnosis, it accounts for a significant portion of esophageal strictures. The longer it goes untreated, the more likely it is that a patient will develop a stricture due to the time-dependent fibrotic (scar tissue) features of the disease.

Medication-induced esophagitis: Many medications can cause pill-induced inflammation of the esophagus. Common culprits include NSAIDs, a type of pain reliever, potassium chloride tablets and some antibiotics. Symptoms often go away on their own, so patients continue to use the medication and develop inflammation. In a small percentage of patients, this can lead to a severe condition like an esophageal stricture.

Radiation therapy can cause a stricture as a side effect. It can damage healthy soft tissue and cause a restriction in the esophagus as a late complication, and the risk increases when more radiation is used.

Endoscopic therapy, which involves inserting a thin, flexible tube with a camera on the end into the throat, can also cause strictures. When used to biopsy or remove cancerous tissue in the esophagus, it can damage the underlying layer of cells, leading to scar tissue and strictures. The risk increases when more of the esophagus is removed.

Esophagectomy, the removal of part of the esophagus, can cause a stricture at the site of surgical joining; this is called anastomotic stricture. This happens in 22 to 50% of cases and often needs further treatments due to a high chance of reoccurrence.

Chemotherapy can also result in a stricture, though this is rare. When it does happen, it’s usually due to an esophagus inflammation caused by infection or the chemotherapy itself.

Thermal injury is a rare cause of esophageal stricture. Accidentally swallowing hot food or liquid, like coffee or tea, can cause this. Usually, these cases can be managed conservatively, meaning without surgery. But there have been cases where the stricture needed more intensive treatments, like stretching the area (endoscopic dilation) or surgery.

Viral or fungal infections like cytomegalovirus, herpes, HIV, or Candida can cause inflammation and stricture in the esophagus. These usually happen in people with weakened immune systems, and painful swallowing is usually present.

Other uncommon causes include using a nasogastric tube for a long time, collagen vascular diseases like scleroderma or lupus, benign mucosal pemphigoid, graft-versus-host disease, an esophageal web in Plummer-Vinson syndrome, Crohn’s disease, and tuberculosis.

Cancerous Strictures

Cancerous causes of esophageal stricture include adenocarcinomas, squamous cell carcinomas, and cancer that has spread to the esophagus from other parts of the body, usually from lung cancer.

Risk Factors and Frequency for Esophageal Stricture

Esophageal stricture, or a narrowing of the esophagus, isn’t common. It affects a small number of people but the risk goes up as people get older. A type of stricture called peptic strictures is actually becoming less common, possibly due to the increasing use of medication (PPIs) to treat stomach acid problems. Risk factors for having peptic stricture include a history of GERD (gastroesophageal reflux disease), hiatal hernia, difficulty swallowing, peptic ulcer disease, and drinking alcohol.

Esophageal strictures can happen to anyone at any age, but the cause tends to vary with age. For example, it’s more common for children and young people to have strictures because of caustic esophagitis or eosinophilic esophagitis. Adults, however, are more likely to have strictures related to acid reflux or due to negative side effects from medications. Strictures caused by cancer are most often found in older people, which makes sense because cancer is generally more common in older people.

• Esophageal stricture is more common in Whites than Blacks or Asians.
• There’s no clear link between sex and esophageal stricture.
• However, men are generally more likely than women to have erosive esophagitis, a condition that can lead to esophageal stricture.

Signs and Symptoms of Esophageal Stricture

When a person has a stricture, or narrowing, in their esophagus, they typically experience one or more of the following symptoms:

• Difficulty swallowing (dysphagia)
• Food getting stuck in the throat (food impaction)
• Painful swallowing (odynophagia)
• Chest pain
• Weight loss

The severity and progression of these symptoms can vary depending on the type of stricture. For example, a benign (non-cancerous) stricture usually develops slowly, while a malignant (cancerous) stricture tends to develop more quickly and may also cause additional symptoms such as heartburn, vomiting, pain while swallowing, upper respiratory symptoms, or chest pain.

It’s also important to note that complications can occur if a stricture goes untreated. For instance, food impaction (food getting stuck in the throat) can lead to serious issues like aspiration (inhaling food into the lungs) or perforation (a hole in the esophagus), and should be dealt with promptly to avoid these outcomes.

The reason for stricture formation can often be determined through a careful history and physical examination. The doctor may inquire about a patient’s swallowing difficulties, previous gastrointestinal diseases or medication use that could cause stomach ulcers and irritation, recent ingestion of harmful substances, past endoscopic treatments or esophageal surgeries, history of radiation therapy, or usage of certain medications like alendronate, tetracycline or other antibiotics, and anti-inflammatory drugs.

In case of peptic stricture, the patient often maintains a good appetite and doesn’t lose weight. However, in case of malignant or refractory strictures, they might show signs of weight loss, anorexia, and long-standing weakness.

Testing for Esophageal Stricture

If you go to your doctor and they think you may have an esophageal stricture, or a narrowing of your esophagus, they will probably suggest certain tests to confirm this. An esophagogastroduodenoscopy or contrast-enhanced esophagogram are common tests used for this. The former involves using a thin tube with a light and camera on the end, called an endoscope, to visualize and examine your esophagus, stomach, and the first part of your small intestine (the duodenum). A contrast-enhanced esophagogram involves drinking a contrast agent, then capturing X-ray images of the esophagus. Both these tests can help spot an esophageal stricture.

In some cases, particularly if you’re having difficulties swallowing (also known as dysphagia), or you’re showing other symptoms, your doctor might also suggest a chest X-ray, or possibly a CT scan. These tests can help rule out other issues with your stomach, such as a foreign body that’s been swallowed and stuck, a hernia, or specific lung conditions.

If your doctor suspects the narrowing might be due to a cancerous growth, they will also likely order a biopsy. This means they will take a small sample of the tissue in your esophagus to look at it under the microscope and check for cancer cells. This is usually done during the endoscopy procedure. Also during this procedure, if your doctor finds a stricture, they might dilate or widen it.

If your stricture is complex (for example, if it’s long, has a rough surface, or a very narrow opening), your doctor might also recommend a procedure called a barium contrast swallow. This involves swallowing a liquid that contains barium, a substance that shows up in X-ray images. This test can give your doctor a better understanding of the location, size, and severity of the stricture.

Finally, an endoscopic ultrasound, where an ultrasound device is attached to the endoscope might also be used. This test provides detailed images of the wall of your esophagus and can help your doctor get a more accurate idea of what’s causing the stricture.

All these tests can help your doctor tell whether your stricture is benign (not harmful in the long term) or malignant (cancerous), which will guide the treatment plan.

Treatment Options for Esophageal Stricture

Strictures, or narrowings within the body’s pipes like the digestive tract, often need treatment to allow normal flow of substances through them. The treatment options include stretching the area with dilators, putting in a tube or stent to keep it open, surgery, and medication. Sometimes, a type of medication-delivering tube called an endoscope is used to expand a small surgical tool or balloon to gently stretch the stricture to allow for increased flow.

People with strictures often experience swallowing difficulties or their food doesn’t pass through normally, a condition known as dysphagia. We have scoring system to assess this condition, originated by Ogilvie et al., that can be applied to all types of strictures, whether benign (noncancerous) or malignant (cancerous). The scores range from 0 to 4, with 0 being no dysphagia and 4 for severe cases where a person is unable to swallow anything.

Once the type of stricture is determined, the plan of how to make it wider or clearer includes choosing the suitable dilation technique, deciding if additional methods are necessary, and how much the area can be safely dilated. Benign strictures are typically treated with endoscopes followed by the suitable course of action for underlying cause of stricture.

There are two main types of dilators: mechanical and balloon. Mechanical dilators include a variety of sizes and materials like rubber. Some pass freely, while others require a guide wire to help in the process. On the other hand, balloon dilators expand by force to widen the stricture. They also vary in size and some have a built-in guide wire and can expand to different sizes.

Dilating a stricture is done by a specialist and is often performed in a manner to facilitate safe and comfortable outpatient care. The dilator’s selection and the method used depend mainly on stricture’s complexity, size and location. Lower strictures in the esophagus, generally peptic in nature, are usually treated safely with mechanical dilators, while complex strictures may require balloon dilators.

This procedure involves first assessing the size of the stricture area to estimate the appropriate dilator size. It’s usually operated gently without using excessive force. A common approach used by many endoscopists is called the “rule of three,” performing up to three dilations per session while successively increasing the dilator size bit by bit. Fluoroscopy, an imaging technique, is sometimes used to aid in navigating complex strictures.

Additional methods that can be used include injection of steroids inside the structure area or the use of steroid-containing gel. Steroids reduce inflammation resulting from dilation, reducing the risk of narrowing restricture. Specific techniques may be considered in highly fibrotic strictures.

Managing strictures can be challenging, as the major problem faced often is the recurrence of the stricture. Generally, a stricture is considered refractory when it consistently prevents enough swallowing space, or recurrent when it’s unable to maintain a satisfactory diameter.

Stents, on the other hand, are used for malignant strictures and those benign strictures that are refractory. It’s a tube that can be placed to keep the space open for a longer period, allowing the tissue to reform so that the space doesn’t narrow. However, the use of stents is widely seen in patients with terminal cancer where they improve symptoms and quality of life.

When dealing with harsh strictures, surgical treatment may be needed, especially when they’re caused by cancer. When necessary, partial or complete removal of the esophagus is performed, along with either creating a channel with the stomach or using a part of the bowel to replace it. In some cases, to relieve symptoms and provide a dietary route, a tube for feeding is placed in the stomach.

What else can Esophageal Stricture be?

When checking for suspected esophageal stricture disease, which is a narrowing of the esophagus, doctors also need to look for other associated conditions. These conditions include:

• Diffuse esophageal spasm: Here, the esophagus contracts unevenly, which results in irregular muscle contractions while swallowing. It could cause chest pain after eating, although swallowing difficulties are often more common. Tests can show abnormalities in the contractions. In some cases, the esophagus gets abnormally squeezed, resulting in a corkscrew-like appearance.
• Achalasia: This disorder occurs when the muscle at the end of the esophagus doesn’t relax properly due to unexplained or infection-related damage. Because of this, food can get trapped at the lower esophagus, leading to difficulties swallowing and bad breath. A specific test can show a “bird beak” appearance which is a key indicator for achalasia if no abnormality is found on a tissue sample examination.
• Pseudo-achalasia: This condition has similar symptoms as achalasia, but it’s caused by cancerous cells invading the lower esophagus. A tissue sample examination can distinguish this condition from other esophagus disorders.
• Esophageal cancer: This type of cancer can sometimes cause an obstruction in the esophagus, leading to difficulties swallowing. An endoscopy, an examination to visualize your esophagus, can identify this condition.

These evaluations are crucial as they inform the management and treatment of esophageal narrowing.

What to expect with Esophageal Stricture

Esophageal stricture, or a narrowing of the esophagus, tends to develop over time and the outcome often depends on when it’s diagnosed and how it’s managed, as well as what has caused it in the first place. For benign, or non-cancerous, esophageal strictures, esophageal dilation—which involves stretching the esophagus—is typically the first form of treatment. However, this procedure carries a 10-30% chance of the stricture recurring, which could lead to additional risks and costs.

If the stricture is caused by stomach acid damage (peptic stricture), the outlook is usually very good when treated early with dilation and long-term use of medications called Proton Pump Inhibitors (PPIs) to reduce acid production. In some cases, strictures are caused by a hiatal hernia, a condition where part of the stomach bulges up through the diaphragm. The surgical correction of this condition results in excellent outcomes with a minimal chance of stricture recurrence and marked improvement in symptoms.

Different techniques have been explored to improve the outcomes and reduce the chance of stricture recurrence. For example, steroid injections or pills during treatment have shown promising results. However, in certain cases where repeated dilation is not effectively relieving symptoms, a stent—or a tube placed in the esophagus to keep it open—may be used for benign strictures.

The prognosis for malignant or cancer-related esophageal strictures depends on the type of cancer, the extent of the tumor, and the stage of the disease. Surgery to remove the tumor tends to provide a better outcome if the cancer hasn’t spread to lymph nodes and surrounding tissue. If a stent is used to manage symptoms in these cases, it usually indicates a poor prognosis.

Possible Complications When Diagnosed with Esophageal Stricture

If an esophageal stricture isn’t treated, it can lead to a number of complications. These can include food getting stuck in the throat, inhaling food particles leading to conditions such as asthma, severe chest pain, damage to the esophagus due to long-term inflammation, and formation of communication passages known as fistulae.

Additionally, procedures to treat esophageal strictures, such as dilation and stent placement, can also have some complications. These include damage to the esophagus, bleeding, more severe bleeding known as hemorrhage, complications from anesthesia such as difficulty in breathing, infection of the lungs resulting from inhaling bacteria, and blood infections. In fact, around 22% of patients develop temporary blood infections from the esophageal dilation, especially in cases involving malignant stricture dilation and multiple dilations. To avoid this, doctors often recommend antibiotics before the procedure. Other potential complications include the stricture coming back, formation of a new stricture, complications in removing the stent, skin growing over the uncovered stent, and displacement of the stent upwards causing a choking sensation and difficult breathing.

• Food impaction
• Inhalation of food particles
• Asthma from inhaling food
• Severe chest pain
• Esophageal damage
• Fistula formation
• Damage to esophagus from treatment
• Bleeding
• Serious bleeding or hemorrhage
• Anesthesia-related complications
• Lung infections
• Blood infections
• Stricture recurrence
• New stricture formation
• Complications in removing stent
• Skin growing over the stent
• Stent displacement causing choking and breathing difficulty

Preventing Esophageal Stricture

A stricture is a complex medical condition that needs a good understanding and active involvement from patients for effective treatment. It’s important for patients to know that stricture treatment could potentially lead to serious complications such as tearing or bleeding in the esophagus. The patients need to be educated about the long-term nature of the illness and chances of it coming back.

Also, it’s essential for them to know that they should seek immediate medical help if they experience symptoms like difficulty swallowing (dysphagia) or food or stomach acid coming back up (regurgitation). If a patient is diagnosed with any conditions which could lead to a stricture, they should be given immediate attention about preventative treatments to decrease the chances of developing these serious complications.