What are the symptoms and treatment options for esophageal stricture?

Symptoms of Esophageal Stricture

The hallmark symptom of esophageal stricture is progressive dysphagia to solid foods more than liquids, which distinguishes it from motility disorders where both solids and liquids cause difficulty swallowing. 1

Primary Clinical Presentation

• Dysphagia for solids is the characteristic and most common symptom, typically progressing from difficulty with solid foods to eventually affecting softer foods as the stricture worsens 1
• Food bolus obstruction can occur, particularly with Schatzki's rings and eosinophilic oesophagitis strictures, representing an acute presentation 1
• Regurgitation commonly accompanies dysphagia, especially in corrosive strictures 1

Symptom Patterns by Stricture Type

Peptic Strictures

• Dysphagia may result from active oesophagitis rather than the stricture itself, and symptoms can improve with PPI therapy alone without requiring dilatation 1
• The severity of dysphagia correlates with both stricture diameter and the presence of active inflammation 1

Schatzki's Ring

• "Schatzki's rule" predicts symptoms based on ring diameter: dysphagia is usual with diameters ≤13 mm, rarely occurs if diameter exceeds 20 mm, with variable symptoms in between 1
• Intermittent dysphagia for solids is typical, often with episodic food impaction 1

Eosinophilic Oesophagitis Strictures

• Daily dysphagia and food bolus obstruction are common presenting features 1
• Chest pain after eating is frequently reported and should raise suspicion for EoE-related stricturing 1
• Spontaneous esophageal perforation can occur and EoE is now the most common cause of this complication across all age groups 1

Corrosive Strictures

• Dysphagia and regurgitation typically develop within 4 months after caustic ingestion 1
• These symptoms should prompt immediate upper gastrointestinal evaluation 1

Treatment Approach

Endoscopic dilatation is the primary treatment for symptomatic esophageal strictures, with the goal of alleviating dysphagia, maintaining oral nutrition, and reducing aspiration risk. 1

Initial Management Strategy

• Perform dilatation with repeat sessions every 1-2 weeks until achieving a target diameter of ≥15 mm with symptomatic improvement 1, 2
• Use wire-guided dilators (bougie or balloon) or endoscopically controlled balloon techniques for all patients to improve safety 2
• Avoid blind passage of weighted (Maloney) dilators as safer alternatives are available 2

Specific Treatment Protocols

For peptic strictures:

• Offer high-dose PPI therapy before and after dilatation, as this significantly reduces the need for repeat dilatation (strong recommendation, high-quality evidence) 1
• Between 40-60% of peptic strictures require only one dilatation session 1
• H2 receptor antagonists are ineffective and should not be used 1

For eosinophilic oesophagitis:

• Combine dilatation with disease-modifying therapy using topical steroids or dietary elimination (strong recommendation, moderate evidence) 1
• Start topical steroids before dilatation when possible, as this approach is more cost-effective than dilatation alone 1
• Warn patients that chest pain during and after dilatation is common (occurs in approximately 8% of cases) 1
• Dilatation in EoE carries no higher perforation risk than other benign conditions (0.38% perforation rate) 1

For corrosive strictures:

• Begin dilatation 3-6 weeks after ingestion for patients with few (<3) short (<5 cm) strictures 1, 3
• Avoid dilatation within the first 3 weeks post-ingestion due to higher complication risk 3, 2
• Use intervals of less than 2 weeks between dilatation sessions 3, 2
• Note that perforation rates are higher (0.4-32%) compared to standard benign stricture dilatation 3, 2

Management of Refractory Strictures

A stricture is defined as refractory when unable to maintain a luminal diameter ≥14 mm after five sequential dilatation sessions spaced 1-2 weeks apart. 1, 2

For refractory cases, escalate treatment as follows:

• Intralesional steroid injection combined with dilatation for strictures with evidence of inflammation (strong recommendation, high evidence) 1
• Temporary placement of fully covered self-expanding removable stents for 4-8 weeks when other methods fail 1
• Consider incisional therapy for refractory Schatzki's rings and anastomotic strictures at experienced centers 1
• Offer surgery to patients who do not respond to or are intolerant of other measures 1

Critical Safety Considerations

• Monitor patients for at least 2 hours post-procedure and ensure they tolerate water before discharge 2
• Suspect perforation if patients develop chest pain, dyspnea, fever, or tachycardia after dilatation 2
• Transient chest pain is common and not necessarily indicative of perforation, but persistent pain warrants contrast-enhanced CT 2
• Use fluoroscopic guidance for high-risk strictures (post-radiation, caustic, long, angulated, or multiple strictures) 1, 2

Common Pitfalls to Avoid

• Do not dilate asymptomatic Schatzki's rings discovered incidentally 1
• Ensure maximal anti-reflux therapy is optimized before labeling a peptic stricture as refractory 2
• For very narrow strictures not allowing adult endoscope passage, limit initial dilatation to 10-12 mm diameter 2
• Consider limiting dilatation to no more than three successive diameter increments in a single session to reduce perforation risk 2