What are the primary causes of esophageal stricture?

Causes of Esophageal Stricture

The primary causes of esophageal strictures are gastroesophageal reflux disease (peptic strictures), caustic ingestion, anastomotic strictures following surgery, radiation-induced injury, and post-ablative therapy complications. 1, 2

Major Etiologic Categories

Peptic (Reflux-Induced) Strictures

• Gastroesophageal reflux disease accounts for over 90% of benign esophageal strictures, making it the most common cause overall 3, 4
• Long-term acid reflux leads to chronic inflammation and subsequent fibrosis in the distal esophagus 5, 4
• These strictures typically occur in the distal esophagus and may be associated with Barrett's esophagus 6, 4
• Impaired lower esophageal sphincter pressure can perpetuate the cycle of reflux and stricture formation 1

Caustic Injury

• Caustic substance ingestion is the second most common cause of benign esophageal strictures 3
• Alkalis are the predominant caustic agents in Western countries, while acid ingestion is more common in developing countries like India 1
• Caustic injury impairs lower esophageal sphincter function, leading to secondary gastroesophageal reflux that worsens stricture formation 1
• These strictures are particularly prone to becoming refractory and carry higher perforation risks (0.4-32%) compared to other etiologies 1

Anastomotic Strictures

• Surgical anastomoses following esophageal resection or reconstruction commonly develop strictures 1, 5
• These are classified as complex strictures (>2 cm, angulated, irregular, severely narrowed) and frequently become refractory 1
• Inadequate mobilization during surgery may lead to tension on anastomoses, increasing stricture risk 7

Radiation-Induced Strictures

• Mediastinal irradiation for thoracic malignancies causes fibrosis and stricture formation 1, 4
• These strictures are complex in nature and often refractory to standard dilatation 1
• Radiation-induced strictures respond less effectively to dilatation compared to peptic strictures 2

Post-Ablative Therapy

• Endoscopic ablation procedures (such as radiofrequency ablation for Barrett's esophagus) can result in stricture formation 1
• These are considered complex strictures with higher rates of refractoriness 1

Less Common Causes

Eosinophilic Esophagitis

• Chronic eosinophilic inflammation leads to esophageal remodeling and stricture formation 5, 4
• These strictures may occur in the upper or mid-esophagus 4

Medication-Induced Injury

• Drug ingestion (particularly doxycycline, NSAIDs, potassium chloride, bisphosphonates) can cause localized injury and stricturing 4
• Strictures typically occur in the mid-esophagus where pills may lodge 4

Infectious Causes

• Candida esophagitis can rarely lead to stricture formation in immunocompromised patients 4

Systemic Diseases

• Scleroderma causes distal esophageal strictures due to impaired motility and severe reflux 4
• Crohn disease can involve the esophagus and cause stricturing 4
• Skin diseases (pemphigoid, epidermolysis bullosa) may cause esophageal strictures 4
• Graft-versus-host disease following bone marrow transplantation 4
• Behçet disease 4

Iatrogenic Causes

• Nasogastric intubation with prolonged placement 4
• Endoscopic sclerotherapy for esophageal varices 4
• Glutaraldehyde contamination during endoscopy 4

Congenital

• Congenital esophageal stenosis presents in childhood but may be diagnosed later 4

Clinical Pitfalls

A critical caveat: when evaluating refractory strictures that fail to respond to dilatation despite achieving adequate diameter (≥14 mm), always consider alternative neuromuscular causes of dysphagia (such as achalasia or esophageal spasm) rather than assuming the stricture itself is the sole problem 1. This prevents unnecessary repeated dilatations and directs appropriate diagnostic workup including manometry.