Esophageal Stricture

The Esophageal stricture is a medical condition in which the esophagus narrows, a modification which leads to the appearance of certain symptoms, such as swallowing difficulties.

Symptoms of Esophageal Stricture

These are the most common symptoms that are encountered in patients diagnosed with esophageal stricture:

• Difficult swallowing (dysphagia)
  • This symptom is progressive, being more obvious when the patient is trying to swallow something solid
  • In more severe cases, the patient might even have difficulties trying to swallow liquids
• Pain upon trying to swallow (odynophagia)
• Weight loss – this occurs as the patients avoids eating because of the pain and difficult swallowing
• Food regurgitation
• Heartburns
• Modified taste in the mouth – bitter or acidic
• Choking
• Constant and chronic coughing
• Shortness of breath
• Belching
• Hiccupping
• Vomiting (digested food or blood)
• Pain in the chest
• Asthma – this is developed as a complication to the constant aspiration of food or acid.

What Causes Esophageal Stricture?

The causes that lead to the appearance of esophageal strictures can be classified into three main categories:

• Medical conditions in which the esophagus is narrowed by inflammatory processes, excess growth of fibrous tissue or cancerous growths
• Medical conditions in which the esophagus is narrowed by the enlargement of the lymph nodes in the area
• Medical conditions in which the smooth muscles and the innervation of the esophagus are affected, with a negative effect on the peristalsis and overall functioning.

These are the most common types of health problems that can cause the appearance of the esophageal stricture:

• Ingestion of toxic substances
• Cancerous growths (neoplastic syndrome)
  • Squamous cell carcinoma
  • Adenocarcinoma
• Therapy for neoplasm (radiation therapy)
• Inflammation of the esophagus
  • Often caused by infectious microorganisms, such as: HIV (human immunodeficiency virus), CMV (cytomegalovirus), HSV (herpes simplex virus) and candida
  • Idiopathic – increased levels of eosinophils
• AIDS (acquired immunodeficiency syndrome)
• Reduced functioning of the immune system (such as the immunosuppression, which is characteristic for the patients who have received a transplant)
• Medication
  • NSAIDs
  • Alendronate
  • Ferrous sulfate
  • Phenytoin
  • Potassium chloride
  • Quinidine
  • Antibiotics (tetracycline)
  • Ascorbic acid
• Dermatological conditions
  • Pemphigus vulgaris
  • Epidermolysis bullosa dystrophica
• Graft versus host disease
• Compression of the esophagus (extrinsic)
• Dissection of cancerous growth (squamous cell carcinoma)
• External force in trauma or injury
• Foreign body stuck in the esophagus
• Post-surgical complication
• Congenital causes
• Peptic stricture
  • GERD (gastroesophageal reflux disease)
  • Zollinger-Ellison syndrome
• Collagen vascular disease
  • Scleroderma
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
• Reflux following the partial resection of the stomach
• Sclerotherapy
• Prolonged period of intubation (nasogastric)
• Crohn disease
• Endoscope injury
• Treatment for esophageal varices.

Treatment

These are the most common methods of treatment recommended for the esophageal stricture:

• Aggressive acid suppression (PPIs)
  • Omeprazole
  • Ranitidine
  • Considered more effective and cost-efficient than H2 blocker therapy
• H2 blocker therapy
• Mechanical dilation (endoscopic)
  • Maloney/Hurst dilators (mercury-filled bougies)
    • Recommended if there are no complications associated with the strictures
    • Indicated in strictures that have a diameter which goes over 1-1.2 cm
    • Cheap method of treatment
    • Performed with the help of the fluoroscope (guidance)
    • Light sedative or no sedative can be administered
    • Can be performed at home by the patient himself/herself
  • Savary-Gilliard dilators (wire-guided bougies)
    • Main characteristics of these dilators – stiff, reusable
    • Recommended for patients who were diagnosed with esophageal strictures that are long, tight and irregular
    • The usage of fluoroscopic guidance is optional
    • Available range varies between 5 and 20 mm
    • Disadvantages include: damage of the wall of the larynx, discomfort
    • Alternative – American dilators – advantages: shorter size, not so much tapered and they are coated with barium (allows for better guidance with the fluoroscope)
  • Balloon dilators
    • Used through the endoscope
    • Direct visualization of the esophageal stricture
    • Disadvantages – high price, one-time usage
    • Fluoroscopic guidance is generally used for the cases that are more difficult
• Corticosteroid injections
  • Beneficial for peptic strictures
  • Cannot be administered for prolonged periods of time, due to the negative effects on the overall health
• Endoscopic stricturoplasty
  • The incisions made at the level of the esophagus are followed by the usage of the Savary-Gilliard dilators
• Pharyngoesophageal puncture
  • Endoscopic dilation technique
  • Used in the esophageal strictures induced by radiation therapy (complete or severe esophageal stricture)
  • It is based on the usage of:
    • Savary-Gillard dilators
    • Endoscopic balloon dilators
    • Puncture
    • ERCP techniques
• Stent
  • Recommended in patients who have failed to obtain positive results from the dilation therapy
  • Temporary placement
  • Risk – recurring of the strictures after the removal of the stent
• Anti-reflux surgery
• Esophageal lengthening
• Esophageal resection and reconstruction (parts from the colon are used for that purpose)
• Minimally invasive procedures
  • Laparoscopic transhiatal esophagectomy
  • Laparoscopic Collis gastroplasty.

Diet

These are the most important recommendations for the diet that the patients with esophageal strictures should follow:

• Avoiding the foods that cause the reflux of the acid into the mouth (spicy, greasy, acidic)
• No alcohol is allowed
• No smoking
• Chocolate and peppermint are forbidden, as they can have negative effects on the already-damaged esophagus
• Smaller meals are recommended to be eaten
• The patient is educated to eat the food slowly, chewing it really well (so as not to add further stress on the esophagus)
• In case of excessive weight, a diet with the purpose of weight loss is going to be established
• If the patient has dental problems, these should be solved (so as to allow for the correct and complete chewing of the esophagus)
• Going to sleep with at least two or three hours after a meal
• Avoiding lying down after a meal (increased risk for acidic reflux or food regurgitation)
• No carbonated beverages are allowed on the diet
• Other forbidden products include: caffeine-based beverages, tomatoes (and products that are made from tomatoes) and citrus fruits.