What are the primary causes of esophageal stricture?

Causes of Esophageal Stricture

Primary Etiologic Categories

The most common causes of esophageal strictures are gastroesophageal reflux disease (GERD), caustic ingestion, post-surgical anastomotic strictures, radiation-induced injury, and complications from endoscopic ablation therapy. 1

GERD-Related Strictures

• Peptic strictures from chronic acid reflux account for the majority of benign esophageal strictures, representing over 90% of cases when combined with caustic injuries 2
• Impaired lower esophageal sphincter pressure perpetuates a cycle of ongoing reflux that worsens stricture formation 1
• These strictures typically respond well to dilatation, with 85-93% of patients achieving good relief when dilated to 13-20 mm 3

Caustic Injury Strictures

• Caustic substance ingestion is a major cause of benign strictures, with alkalis being the predominant agents in Western countries 1
• The injury impairs lower esophageal sphincter function, creating secondary gastroesophageal reflux that compounds the stricture formation 1
• These strictures are particularly challenging—they are prone to becoming refractory and carry significantly higher perforation risks (0.4-32%) compared to peptic strictures 1, 4
• Stricture formation typically occurs within 4 months after caustic ingestion 4

Post-Surgical Anastomotic Strictures

• Surgical anastomoses following esophageal resection or reconstruction commonly develop strictures, classified as complex strictures that frequently become refractory 1
• Inadequate mobilization during surgery may create tension on anastomoses, increasing stricture risk 1
• These require more aggressive management strategies than simple peptic strictures 3

Radiation-Induced Strictures

• Radiation therapy causes complex strictures that are often refractory to standard dilatation 1
• These strictures respond less effectively to dilatation compared to peptic strictures and require specialized management approaches 1
• Dilatation appears less effective in radiation-induced strictures than in reflux-induced ones 3

Post-Ablation Strictures

• Endoscopic ablation procedures (radiofrequency ablation, photodynamic therapy) result in stricture formation at varying rates depending on the technique 3
• Stricture rates are significantly higher after photodynamic therapy (36%) compared to other ablation forms 3
• When endoscopic mucosal resection precedes ablation, stricture rates increase (12% vs 6% without prior resection) 3
• For early squamous cell neoplasia treated with RFA, stricture rates range from 14-23%, substantially higher than for Barrett's esophagus treatment 3

Eosinophilic Esophagitis (EoE)

• EoE is now the most common cause of food bolus obstruction in patients under age 50 years 3
• It represents the second most common benign esophageal disease and is the most common cause of spontaneous esophageal perforation 3
• EoE is often underdiagnosed despite being 50 times more common than achalasia 3

Pathophysiologic Mechanisms

The Three-Stage Process

• Esophageal stricture development involves three sequential stages: structural damage to the esophageal epithelial barrier, chronic inflammation, and severe fibrosis 5
• Dysfunction or damage to the esophageal epithelial barrier is the initiating mechanism leading to stricture formation 5
• Contributing factors include overdifferentiation of fibroblasts, inflammatory responses that fail to heal timely, and impaired epithelial barrier function 5

Clinical Pitfall

When evaluating refractory strictures that fail to respond to dilatation, consider alternative neuromuscular causes of dysphagia such as achalasia or esophageal spasm rather than assuming the stricture itself is the sole problem. 1 This is a common diagnostic error that leads to repeated unsuccessful dilatations when the underlying pathology is actually a motility disorder.