Oesophageal Strictures

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Oesophageal strictures refer to the narrowing of the oesophagus, leading to progressive difficulty in swallowing (dysphagia). This can be caused by chronic inflammation, fibrosis, or malignancy.

Aetiology

  • Gastro-oesophageal reflux disease (GORD): most common cause due to chronic acid exposure leading to inflammation and fibrosis.
  • Oesophageal cancer: can cause malignant strictures.
  • Post-surgical or post-radiation strictures: due to fibrosis following treatment for head, neck, or oesophageal malignancies.
  • Eosinophilic oesophagitis: chronic allergic inflammation leading to oesophageal remodelling.
  • Corrosive ingestion: accidental or intentional ingestion of caustic substances (e.g., acid or alkali burns).
  • Anastomotic strictures: occurring after oesophageal surgery.
  • Infectious strictures: secondary to conditions like oesophageal candidiasis, tuberculosis, or herpes simplex virus in immunocompromised individuals.

Pathophysiology

  • Chronic inflammation or injury to the oesophageal mucosa leads to fibroblast activation and collagen deposition.
  • Fibrosis and scarring result in luminal narrowing and reduced oesophageal motility.
  • As the stricture worsens, food impaction, dysphagia, and aspiration may occur.

Risk factors

  • Chronic GORD (most common).
  • History of oesophageal surgery.
  • Prolonged nasogastric tube placement.
  • Use of bisphosphonates or NSAIDs (drug-induced strictures).
  • Corrosive ingestion (e.g., bleach, lye).
  • Radiation therapy to the neck or chest.
  • Immunosuppression (risk of infectious oesophagitis).

Signs and symptoms

  • Progressive dysphagia: initially for solids, later for liquids.
  • Odynophagia: painful swallowing, especially in inflammatory strictures.
  • Regurgitation of undigested food.
  • Heartburn: common in GORD-related strictures.
  • Weight loss: suggests malignancy.
  • Chronic cough or aspiration: due to difficulty swallowing.

Investigations

  • Endoscopy with biopsy (gold standard): identifies the cause and rules out malignancy.
  • Barium swallow: useful for assessing the length and severity of the stricture.
  • Oesophageal manometry: used if dysmotility disorders are suspected (e.g., achalasia).
  • 24-hour pH monitoring: confirms GORD in reflux-related strictures.

Management

1. Conservative Management:

  • Dietary modifications: soft or pureed foods in mild cases.
  • Proton pump inhibitors (PPIs): high-dose PPIs (e.g., omeprazole 40 mg OD) to prevent recurrence in GORD-related strictures.

2. Endoscopic Treatment:

  • Oesophageal dilation: first-line for benign strictures; performed with balloon or bougie dilators.
  • Intralesional steroid injections: used for refractory strictures to reduce inflammation and fibrosis.
  • Stent placement: for malignant strictures or recurrent strictures unresponsive to dilation.

3. Surgical Management:

  • Oesophagectomy: if malignancy is confirmed.
  • Fundoplication: in severe GORD cases with persistent strictures despite PPIs.
  • Stricture resection: considered for severe refractory benign strictures.
GastroenterologymypanotesOesophageal Strictures