Oesophagus Strictures

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Oesophageal strictures is characterised by a narrowing of the oesophagus, the muscular tube that connects the throat to the stomach. This condition occurs when scar tissue forms in the oesophageal lining, leading to a decreased diameter and impaired passage of food and liquids.

Gastro-oesophageal reflux disease (GORD)
One of the primary causes of oesophageal strictures is gastro-oesophageal reflux disease (GORD). GORD occurs when stomach acid and digestive juices flow back into the oesophagus, resulting in irritation, inflammation, and ultimately, the formation of scar tissues. Over time, these scars can lead to the narrowing of the oesophagus, causing strictures to develop.
Hiatal Hernia
A hiatal hernia is another factor contributing to the development of oesophageal strictures. This condition occurs when a portion of the stomach pushes through the diaphragm and into the chest cavity. Hiatal hernias can put additional pressure on the oesophagus, leading to chronic irritation and the formation of scar tissue.
Substance ingestion
Caustic injuries occur when toxic substances, such as strong acids or alkalis, come into contact with the oesophageal lining. These substances can cause severe burns, leading to scar tissue formation and subsequent strictures. Accidental ingestion of corrosive substances, or intentional ingestion in cases of self-harm or substance abuse, are common causes of caustic injuries.
Radiation Therapy
Patients who undergo radiation therapy for cancers in the chest or upper abdomen may develop oesophageal strictures as a side effect. Radiation can cause scarring and fibrotic changes in the oesophageal tissues, leading to narrowing and strictures. The risk and severity of strictures depend on factors such as the radiation dose, frequency, and specific area of treatment.

1. Inflammation and Fibrosis: The most common cause of oesophageal strictures is chronic gastro-oesophageal reflux disease (GORD). In GORD, the reflux of stomach acid and bile into the oesophagus leads to inflammation of the lining of the oesophagus, known as eosinophilic oesophagitis. This inflammation triggers an immune response, causing the release of inflammatory mediators and the infiltration of eosinophils and other immune cells. Over time, this chronic inflammation stimulates the production of collagen, a fibrous protein that strengthens connective tissues. Excessive collagen deposition results in the development of fibrosis within the oesophageal lining and muscle layers.
2. Scar Tissue Formation: When the oesophageal lining is repeatedly damaged due to chronic reflux, ulcers can develop. As these ulcers heal, they undergo a process called angiogenesis, where new blood vessels form to support tissue repair. However, the healing process can be flawed, leading to the formation of scar tissue within the oesophagus. The scar tissue lacks the flexibility and elasticity of normal oesophageal tissue, resulting in narrowing and rigidification of the oesophageal lumen.
3. Muscular Dysfunction: Oesophageal strictures may also occur due to dysfunction of the muscular layers in the oesophagus. The oesophageal muscles contract in a coordinated manner to propel food from the throat into the stomach. Dysmotility disorders, such as achalasia or diffuse oesophageal spasm, can disrupt this normal muscular function. In achalasia, the lower oesophageal sphincter fails to relax, leading to impaired passage of food through the oesophagus. Over time, the constant pressure on the oesophageal wall can cause the development of strictures.
4. External Compression: Oesophageal strictures can also result from external compression of the oesophagus by neighbouring structures. For example, tumours originating from surrounding organs like the lungs, mediastinum, or the upper digestive tract can exert pressure on the oesophagus, leading to narrowing and subsequent stricture formation. Additionally, conditions like aortic aneurysms, goitres, or lymphadenopathies can also contribute to external compression and subsequent strictures.

1. Gastro-oesophageal reflux disease (GORD)
2. Acid Reflux:
While GORD is a specific condition, occasional acid reflux can also contribute to the risk of developing oesophagus strictures. Acid reflux occurs when stomach acid escapes into the esophagus, causing a burning sensation known as heartburn. Frequent episodes of acid reflux can lead to chronic inflammation in the oesophagus and subsequent scar tissue formation, increasing the likelihood of strictures.
3. Chemical Ingestion:
Ingesting certain corrosive chemicals or substances can severely damage the oesophageal lining and potentially result in strictures. Accidental consumption of chemicals like household cleaners, industrial solvents, or battery acid can cause immediate injury to the oesophagus. Inflammation and subsequent scarring can lead to the narrowing of the oesophagus, making swallowing difficult or painful.
4. Radiation Therapy:
Patients who have undergone radiation therapy as part of their cancer treatment may also be at risk for developing oesophagus strictures. Radiation can cause damage to healthy cells and tissues, leading to scar formation. Depending on the radiation dosage and area of treatment, strictures can develop in the esophagus, making it challenging for patients to swallow food or liquids.
5. Medications:
Certain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and bisphosphonates, have been associated with an increased risk of oesophagus strictures. Using these medications frequently or for long durations can irritate and damage the oesophagus, ultimately leading to a narrowing of the passage.

1. Difficulty Swallowing (Dysphagia): One of the most noticeable symptoms of oesophageal strictures is difficulty or pain while swallowing food or liquids. Initially, this difficulty may only occur when eating solid foods, but it can progressively worsen, affecting the ability to swallow even soft or liquid substances.
2. Feeling of Obstruction: Patients with oesophageal strictures may experience a sensation of having something stuck or lodged in their chest or throat after eating. This can be accompanied by discomfort or pain, making it uncomfortable to swallow or even breathe properly.
3. Chest Pain or Heartburn: Some individuals with oesophageal strictures might also experience chest pain, often mistaken for heart pain (angina). This pain can be similar to heartburn but may persist even after taking antacids or acid reflux medications.
4. Regurgitation or Vomiting: Oesophageal strictures can cause food or liquid to come back up from the stomach, leading to regurgitation or vomiting. This can occur shortly after eating or even hours later when the congested area in the oesophagus prevents the normal flow of food downward.
5. Unintentional Weight Loss: As the narrowing of the oesophagus interferes with proper food intake, individuals with strictures may experience unintentional weight loss. The limited ability to swallow and consume enough calories can result in malnutrition and weakness over time.
6. Hoarseness or Chronic Cough: In some cases, oesophageal strictures can cause irritation or inflammation in the throat, leading to hoarseness or a chronic cough. This symptom is more commonly associated with strictures caused by acid reflux or conditions like eosinophilic esophagitis.

• History and examination: To begin the diagnostic process, a comprehensive medical history and physical examination are essential. A PA will inquire about the patient's symptoms, such as difficulty or pain while swallowing, regurgitation, heartburn, weight loss, and any previous incidents of food impaction.

• Endoscopy

• Barium swallow test to visualize and assess the oesophagus.

• CT scans or MRI scans may be used to evaluate the oesophagus for potential complications, such as obstruction or erosion.

1. Lifestyle Modifications:
These may include losing weight, avoiding trigger foods or beverages (such as spicy, fatty, or acidic foods), abstaining from smoking, and adopting an upright posture during and after meals. These changes aim to reduce reflux and alleviate symptoms associated with oesophageal strictures.
2. Pharmacological Therapy:
NICE recommends the use of proton pump inhibitors (PPIs) as a first-line pharmacological treatment for oesophageal strictures. PPIs effectively reduce the acid production in the stomach, helping to heal the damaged oesophageal tissues and alleviate symptoms. Depending on the severity of the stricture, NICE may suggest a short-term or long-term use of PPIs. The dosage and duration of treatment may vary among individuals.
3. Endoscopic Dilatation:
Endoscopic dilatation is a procedure performed by a gastroenterologist to widen the narrowed part of the oesophagus. The procedure involves using an endoscope, a flexible tube with an inflatable balloon or a dilator, to stretch the scar tissue and widen the oesophagus. The number of dilatations required may vary,
4. Surgical Intervention:
In cases where lifestyle modifications, pharmacological therapy, and endoscopic dilatation fail to provide significant improvement, NICE suggests considering surgical intervention.

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