Esophageal Strictures

What is an esophageal stricture?

An esophageal stricture is an abnormal narrowing of your esophagus. Your esophagus is the swallowing tube that runs through your chest, from your mouth down to your stomach. Stricture is when any channel or passageway in your body becomes narrower or constricted. A stricture can make it hard for things to pass through that channel. In your esophagus, a stricture can cause difficulty swallowing.

Many different disease processes can cause esophageal strictures. These processes can occur from inside or outside of your esophagus. Processes on the inside cause the inner lining (mucosa) to swell and/or stiffen so that it no longer stretches when you swallow. Narrowing from outside the esophagus can occur due to pressure from neighboring organs or growths. These processes usually happen slowly.

How serious is an esophageal stricture?

Healthcare providers take esophageal strictures seriously because they can affect your swallowing and are likely to worsen with time. Although they usually develop slowly, healthcare providers prefer to treat them as soon as possible to prevent them from worsening. Most strictures are treatable with minor interventions. However, a small percentage of them are due to cancer, which is more serious.

What are the symptoms of an esophageal stricture? What does it feel like?

The first and most common symptom you’ll notice is that it’s getting harder to swallow. You might be able to manage this for a while by taking smaller bites and chewing more thoroughly. You might also begin avoiding tougher foods without realizing it. But as the stricture worsens, these adjustments help less. You might feel like there’s a lump in your throat, or like the muscles in your throat aren’t working.

You might also experience:

• Noncardiac chest pain, which is related to your esophagus.
• Coughing or choking when you try to swallow.
• Regurgitation, or food coming back up.
• Unintended weight loss from reduced food intake.

What is the most common cause of esophageal stricture?

Most esophageal strictures (as many as 75%) result from chronic acid reflux. That’s when stomach acid routinely backwashes into your esophagus and irritates the mucous lining. Chronic acid reflux causes chronic inflammation inside your esophagus. Over time, this can lead to scarring (fibrosis). Scar tissue narrows your esophagus. This can happen in part of it or all of it, depending on how far the acid travels.

Types of causes

Causes of esophageal stricture fall into a few main types:

Chronic esophagitis

Most of the common causes of esophageal stricture are types of chronic esophagitis — long-term inflammation of your esophagus lining. Chronic inflammation causes swelling and scarring. Chronic acid reflux is the most common cause of chronic esophagitis, but there are several others, including:

• Pill esophagitis. Drug-induced esophagitis is the erosion of your esophagus lining from swallowing certain medications too often, especially NSAIDs (nonsteroidal anti-inflammatory drugs) and acetaminophen. Potassium can also cause it.
• Infectious esophagitis. Chronic viral infections, including HPV, HSV-1 and CMV, and fungal infections like Candida albicans, can cause esophagitis in people with weaker immune systems.
• Eosinophilic esophagitis. This rare autoimmune disease causes your immune system to overreact to potential allergens, triggering chronic inflammation. It can begin in childhood.

Injury or trauma

Traumatic injury to your esophagus lining can also cause scarring and stricture. This includes accidental, intentional and iatrogenic injuries (related to medical treatment). Injuries can cause swelling and scarring either inside or outside of your esophagus. When it’s outside, it might compress your esophagus. Some causes include:

• Caustic ingestion. Accidentally or intentionally swallowing something caustic or corrosive.
• Thermal injury. Accidentally swallowing something very hot and burning your esophagus.
• Cancer treatments. Radiation therapy to treat cancer in the area can cause inflammation in your esophagus (mucositis). Radiation-induced esophageal stricture (RIES) is a possible side effect. Surgery to remove cancer from your esophagus could also cause scarring and stricture.

Cancer

Esophageal cancer is an uncommon but possible cause of esophageal stricture. When this happens, it isn’t inflammation and scarring that narrows your esophagus but the overgrowth of cancer cells. This overgrowth occurs rapidly, compared with the inflammation and scarring process. If you develop symptoms like difficulty swallowing quickly and unexpectedly, see a healthcare provider right away.

Most cases of esophageal cancer are related to chronic esophagitis, often from chronic acid reflux. In some cases, chronic esophagitis can cause cellular changes in the lining of your esophagus. These changes, known as intestinal metaplasia or Barrett’s esophagus, can lead to cancerous changes. When tumors develop outside of your esophagus, they can compress it. Cancers of the esophagus include:

• Adenocarcinoma.
• Squamous cell carcinoma.
• Metastatic cancer (spread from somewhere else, like your lungs).

What are the risk factors for getting an esophageal stricture?

You might be more likely to get an esophageal stricture if you have a history of:

• Gastroesophageal reflux disease.
• Eosinophilic esophagitis.
• Frequent use of over-the-counter (OTC) pain relievers.
• Cancer treatment in the neck or chest region.

How is an esophageal stricture diagnosed?

Esophageal disorders are often diagnosed by a gastroenterologist. They’ll review your symptoms and health history and then look for evidence of the stricture, using one of two common tests. The first of these is a type of X-ray called an esophagram, also called a barium swallow test. For this test, you swallow a chalky substance called barium, and the X-ray machine takes live video of you swallowing.

An alternative test is called an upper endoscopy or EGD test. For this one, you’ll be sedated, and your gastroenterologist will pass an endoscope down your throat through your esophagus. The endoscope is a tiny camera on the end of a long, thin tube. It’ll show the inside lining of your esophagus in detail. Your provider can also take a biopsy through the endoscope, if necessary, to help diagnose a disease.

What is the treatment for an esophageal stricture?

The goal of treatment for an esophageal stricture is to widen the opening again so that you can swallow adequately and comfortably. For most strictures, esophageal dilation will accomplish this. Dilation means stretching the opening with a balloon or cylinder that widens a little at a time. Dilation is usually successful in treating simple strictures. Complex strictures may need more complex treatment.

Healthcare providers consider a stricture to be simple if it’s a relatively small area, has straight borders and is still wide enough for you to swallow solids through it. Strictures caused by chronic esophagitis are usually simple. A complex stricture, on the other hand, may be long or irregular, or so narrow that you can only swallow liquids. Cancer, injury or trauma may cause more complex esophageal strictures.

Dilation

Dilation is an outpatient procedure that you’ll have once a week or so for several weeks, until your esophagus reaches its target diameter. During each session, your provider will widen (dilate) the dilator incrementally. Most strictures improve with a few sessions, but some complex strictures are refractory (resistant) to dilation, or they come back later (recur). These strictures may require other treatments.

Other treatments

Refractory or recurrent esophageal strictures that don’t respond to dilation alone may require a combination of treatments. Cancerous (malignant) strictures may require a different approach entirely. Since treating the cancer itself is the top priority, providers often defer dilation in these cases. They might need to do surgery or other treatments first and address your stricture in more temporary ways.

Additional treatments include:

• Medication. Providers sometimes use steroid injections at the site of the stricture to reduce inflammation and to prevent or delay the recurrence of the stricture after dilation. Researchers are testing injections of an alternative medication called mitomycin C for preventing fibrosis.
• Endoscopic stricturoplasty. Also called incisional therapy, stricturoplasty is a way of breaking up the scar tissue in your stricture with an electrosurgical needle knife. Your provider will make up to eight incisions (cuts) in each session, working through an endoscope. It might take a few sessions.
• Stenting. A stent is a small tube used to prop open passageways in your body that have become too narrow. Providers sometimes place stents to help prop open an esophageal stricture after dilation therapy. They also may use stents for malignant strictures that haven’t been dilated.
• Surgery. Esophagectomy — surgery to remove part or all of the esophagus — may be necessary for malignant strictures and those that don’t respond to other treatments. If you have chronic acid reflux, your provider might suggest a minor operation to fix it to prevent further damage.

Can esophageal strictures be prevented?

Not all causes are preventable, but some of the most common ones are. If you have symptoms of esophagitis or chronic acid reflux — like heartburn or chest pain — see your healthcare provider. It’s important to realize that these symptoms aren’t just a nuisance but a sign that real damage is occurring. They’re also usually treatable, once your healthcare provider has determined the cause.

Can esophageal stricture be cured?

Esophageal strictures are treatable, and most will respond to conservative treatments like dilation, which works quickly to relieve your symptoms. Some complex strictures are a little trickier to treat. They might require extended treatment, multiple treatments or more intensive treatments, like surgery. It’s also important to address the underlying cause of your stricture to prevent it from happening again.

How soon will I feel better?

Dilation works progressively, opening your esophagus a little at a time. It’ll get a little easier to swallow after each session, but you might also feel a little sore. Simple strictures can usually be successfully dilated in a matter of weeks. Considering how long it takes for most strictures to develop, this is a pretty fast recovery. If you need more complex treatment, your provider can give you an idea of what to expect.

Should I change my diet while living with an esophageal stricture?

You might need to change your diet to make swallowing easier when you have an esophageal stricture. You might also need to adjust your diet before and after treatment for your stricture. Your healthcare provider will give you specific instructions. Providers usually recommend a gastrointestinal soft diet for esophageal strictures. A soft diet is low in fiber, easy to digest and gentle going down your food pipe.

When should I contact my healthcare provider?

Contact a healthcare provider if you have any symptoms of esophagitis or difficulty swallowing. Seek immediate care if you:

• Get food stuck in your throat.
• Can’t swallow solids.
• Accidentally inhale a piece of food.
• Develop severe chest pain.