Esophageal stricture
Esophageal stricture is a fixed luminal narrowing that produces progressive dysphagia to solids, most often a benign peptic stricture from chronic reflux but always requiring endoscopy with biopsy to exclude malignancy. Management is endoscopic dilation of the narrowed segment plus treatment of the underlying cause, with stenting or resection reserved for malignant obstruction.
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What this article covers
- Overview
Definition: esophageal stricture is a fixed, mechanical narrowing of the esophageal lumen that impedes passage of a solid food bolus, distinct from a motility disorder because the defect is structural.
- Epidemiology
Peptic stricture is the most common benign stricture, arising in patients with long-standing, often poorly controlled gastroesophageal reflux disease.
- Risk factors
Chronic, poorly controlled gastroesophageal reflux disease: the dominant risk factor for peptic stricture, from repeated acid-mediated injury and fibrotic healing at the squamocolumnar junction (Gastroesophageal reflux disease GERD).
- Pathophysiology
Repeated mucosal injury: an inciting insult, acid reflux, caustic chemical, ionizing radiation, eosinophilic inflammation, or anastomotic healing, damages the esophageal mucosa and submucosa.
- Clinical features
Progressive dysphagia to solids: the hallmark, described as food sticking, hanging up, or moving slowly, at a reproducible level and worsening with denser foods such as meat or bread.
- Differential diagnosis
Esophageal cancer: progressive dysphagia for solids then liquids with weight loss in an older adult with risk factors, distinguished from a benign stricture only by biopsy showing malignant cells (Esophageal cancer).
- Diagnosis
A stricture is confirmed by direct visualization at upper endoscopy, and biopsy of the narrowed segment is essential and confirmatory to exclude malignancy before any stricture is labeled benign.
- Management
Confirm the cause first, then dilate: obtain biopsies at the index endoscopy; once malignancy is excluded, proceed to endoscopic dilation as first-line treatment.
- Complications
Esophageal perforation: the most feared complication of dilation, more likely with a long, tight, angulated, or caustic stricture and aggressive single-session dilation; suspect it with chest or back…
- Prognosis
Most benign strictures respond well to a staged dilation program combined with treatment of the underlying cause, with symptomatic relief in the large majority of patients, though some require intermittent repeat dilation over years.
- Prevention
Optimize long-term acid suppression after dilation of a peptic stricture: omeprazole 20 mg PO once daily indefinitely, reassessed rather than stopped once dysphagia improves.
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Related articles
- Gastroesophageal reflux disease (GERD)
GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.
- Esophageal cancer
Esophageal cancer comprises squamous cell carcinoma, driven by tobacco, alcohol, and caustic or motility injury to the upper and mid esophagus, and adenocarcinoma, arising from GERD-driven Barrett esophagus distally, both presenting with progressive dysphagia from solids to liquids plus weight loss. Diagnosis is by upper endoscopy with biopsy, staged with CT, PET, and endoscopic ultrasound, and treatment is stage-directed from endoscopic resection through esophagectomy with perioperative chemotherapy or chemoradiation to palliative chemoradiation and stenting.
- Eosinophilic esophagitis
Eosinophilic esophagitis is a chronic, immune/antigen-mediated disease of the esophagus that presents with solid-food dysphagia and food impaction in young atopic men, diagnosed by endoscopic biopsy showing 15 or more eosinophils per high-power field after excluding other causes. Management follows the three D's: dietary elimination, drug therapy with a PPI and/or swallowed topical corticosteroids, and dilation for fibrostenotic strictures.
- Achalasia
Achalasia is a primary esophageal motility disorder from myenteric plexus degeneration that causes failure of lower esophageal sphincter relaxation and aperistalsis, producing dysphagia to solids and liquids with regurgitation. Diagnosis requires endoscopy to exclude pseudoachalasia followed by esophageal manometry, and definitive treatment is pneumatic dilation, laparoscopic Heller myotomy, or POEM.
- Barrett esophagus
Barrett esophagus is metaplasia of the distal esophageal squamous lining into intestinal columnar epithelium driven by chronic GERD, and it is the established precursor of esophageal adenocarcinoma. Diagnosis requires endoscopy showing salmon-colored mucosa above the gastroesophageal junction confirmed by biopsy showing intestinal metaplasia with goblet cells, and management, from surveillance interval to endoscopic ablation, is dictated entirely by the graded dysplasia.
- Esophagitis
Esophagitis is mucosal inflammation of the esophagus with four principal causes, reflux, pill-induced, infectious, and caustic or radiation injury, each with a distinguishing pattern confirmed by upper endoscopy with biopsy or brushings. Management is cause-directed: acid suppression for reflux, stopping the offending pill with upright water intake, and targeted antimicrobials (fluconazole, acyclovir, or ganciclovir) for the specific infectious organism.
- Esophageal rupture
Esophageal rupture is a full-thickness tear of the esophageal wall, most often iatrogenic after endoscopy or spontaneous (Boerhaave syndrome) from forceful vomiting, that spills contaminated contents into the mediastinum and causes rapidly fatal mediastinitis and sepsis without emergent source control. CT with oral water-soluble contrast or a contrast esophagram confirms the leak, and treatment combines resuscitation, broad-spectrum antimicrobial therapy, and either emergent surgical repair or endoscopic stenting depending on the size, location, and time since perforation.
- Dysphagia (oral and esophageal)
Dysphagia is difficulty swallowing, and the history alone localizes it to oropharyngeal disease, marked by choking or nasal regurgitation at the start of a swallow, or esophageal disease, marked by food sticking seconds later. Esophageal dysphagia with solids alone points to a mechanical obstruction worked up first with upper endoscopy, while dysphagia for solids and liquids together points to a motility disorder worked up with barium esophagram and manometry.