From the Guidelines
Esophageal strictures are most effectively managed with endoscopic dilation, and the main risk factors include gastroesophageal reflux disease (GERD), eosinophilic esophagitis, radiation therapy to the chest, caustic ingestion, prolonged nasogastric tube placement, and prior esophageal surgery, as supported by the most recent guidelines 1. The management of esophageal strictures typically begins with endoscopic dilation, using either bougie dilators or balloon dilators to gradually stretch the narrowed area.
- For GERD-related strictures, proton pump inhibitors (PPIs) like omeprazole 20-40mg daily or pantoprazole 40mg daily are essential to prevent recurrence, as indicated by the guidelines 1.
- Refractory strictures may require temporary stent placement, steroid injection (triamcinolone 40mg/ml injected in quadrants at the stricture site), or incisional therapy.
- For eosinophilic esophagitis-related strictures, topical steroids such as fluticasone 440mcg twice daily or budesonide 1mg twice daily, along with dietary modifications, are important adjuncts to dilation, as suggested by the evidence 1. Some key points to consider in the management of esophageal strictures include:
- Severe or recurrent strictures may necessitate multiple dilations every 2-4 weeks until adequate esophageal patency is achieved.
- Patients should be advised to eat slowly, chew thoroughly, and avoid large food boluses to prevent food impaction.
- The goal of therapy is to achieve and maintain an esophageal lumen of at least 13-15mm, which typically allows for comfortable swallowing of a normal diet and improves nutritional status and quality of life, as recommended by the guidelines 1.
From the Research
Risk Factors for Esophageal Stricture
- Caustic ingestion, particularly strong acids or alkalis, is a significant risk factor for esophageal stricture 2
- Gastroesophageal reflux disease (GERD) increases the risk of esophageal stricture, with factors such as obesity, tobacco smoking, and genetic predisposition contributing to GERD 3, 4, 5
- Older age, longer duration of reflux symptoms, and abnormal esophageal motility are also associated with an increased risk of stricture formation 6, 5
- Prior dysphagia, hiatus hernia, peptic ulcer disease, and heavy alcohol use are additional risk factors for esophageal stricture 5
- Mucosal damage, as assessed by emergency endoscopy, and certain laboratory results, such as hyperleukocytosis and a low prothrombin ratio, can also indicate a higher risk of developing a stricture 2
Management Options for Esophageal Stricture
- Relief of dysphagia can be accomplished using polyethylene or mercury-filled dilators or balloons 6
- Proton pump inhibitors (PPIs) are commonly used to heal associated esophagitis and prevent stricture recurrence 3, 4, 6, 5
- Lifestyle changes, such as weight loss, smoking cessation, and avoiding lying down after meals, can also help manage GERD and reduce the risk of stricture 3, 4
- Surgical treatment, including fundoplication and magnetic sphincter augmentation, may be reserved for patients with intractable esophagitis, irreversibly damaged esophagus, or extraesophageal manifestations 3, 4, 6
- New endoscopic and less invasive surgical procedures are emerging as alternative treatment options 3, 4