Oesophageal stricture

What is an oesophageal stricture?

An oesophageal stricture is an abnormal narrowing of your oesophagus (gullet), the muscular tube that carries food and drink from your mouth to your stomach. This narrowing can make swallowing difficult and, without treatment, tends to get worse over time.

What are the symptoms of an oesophageal stricture?

Symptoms usually develop gradually, and often start with difficulty swallowing solid food. You might notice:

• Difficulty or pain when swallowing, or a feeling that food is stuck in your throat or chest
• Needing to take smaller bites, chew more, or avoid tougher foods
• Coughing, choking or gagging when you swallow
• Regurgitation, or food and drink coming back up
• Heartburn
• Unintended weight loss

As the narrowing gets worse, you may find it hard to swallow liquids as well as solids. Rarely, food can become completely stuck above the stricture. This needs urgent treatment to clear the blockage.

What are the causes of an oesophageal stricture and who is at risk?

The most common cause by far is long-term acid reflux (gastro-oesophageal reflux disease, or GORD), which accounts for up to 80% of cases. Stomach acid repeatedly irritates the lining of your oesophagus, causing inflammation that can turn into scar tissue, narrowing the passage. Other causes include:

• Webs or rings – thin extensions of tissue in the oesophagus. Webs are more common in women and may be linked to iron deficiency anaemia. One type of ring, called a Schatzki ring, is more common in men over 50 and often occurs alongside a hiatus hernia
• Eosinophilic oesophagitis – a rare condition where your immune system overreacts to allergens, causing chronic inflammation
• Certain medications taken too often, particularly anti-inflammatory painkillers
• Radiotherapy to your neck or chest
• Scarring after oesophageal surgery
• Swallowing a corrosive or very hot substance
• Infections, in people with a weakened immune system
• Oesophageal cancer, which narrows the oesophagus through the rapid overgrowth of cells rather than scarring.

You may be more at risk if you have long-standing GORD, a hiatus hernia, eosinophilic oesophagitis, or take over-the-counter pain relievers often. If your swallowing difficulty comes on and gets worse quickly, rather than slowly over time, this can be a sign of a more serious cause, so see a doctor right away.

Are there different types of oesophageal stricture?

Strictures are usually described in a few ways.

• Benign or malignant: Benign strictures are non-cancerous and usually caused by long-term inflammation or scarring. Malignant strictures are caused by cancer.
• Simple or complex: A simple stricture is short with straight edges, and is usually still wide enough for solid food to pass through. A complex stricture is longer, uneven, or so narrow that only liquids can get through. Complex strictures are harder to treat and more likely to recur.
• By cause: For example, peptic strictures (from acid reflux, the most common type), radiation-induced strictures, and anastomotic strictures, which form at the site of previous oesophageal surgery.

How is an oesophageal stricture diagnosed?

Your GP can refer you to hospital for tests, which usually include one or both of the following:

• Barium swallow: You drink a liquid that shows up clearly on X-ray, so the doctor can see where your oesophagus is narrowed and measure the length of the narrowing
• Gastroscopy (upper endoscopy): A thin, flexible tube with a camera is passed down your throat, usually with a local anaesthetic throat spray and/or light sedation. This lets the doctor examine the lining of your oesophagus and stomach directly, and take a biopsy (small tissue sample) if needed to check for cancer or other causes

If your stricture might be cancerous, you may also need a CT scan or endoscopic ultrasound to see how far it extends.

How is an oesophageal stricture treated?

Non-surgical treatment

The main treatment for most strictures is dilation – gently stretching the narrowed area with a balloon or a series of increasingly wide dilators, done during an endoscopy. You'll usually need this repeated every week or so over several sessions until your oesophagus reaches a comfortable width. It's common to need more than one round of treatment over time, as strictures can recur.

Other treatments can include:

• medication, such as proton pump inhibitors (like omeprazole or lansoprazole) to reduce acid reflux and lower the chance of the stricture returning, or steroids to reduce inflammation
• steroid injections at the site of the stricture during dilation, to help prevent it recurring
• stenting – placing a small tube to hold the stricture open, most often used for cancerous strictures or ones that keep coming back after dilation
• a feeding tube, in severe cases where you can't get enough nutrition by mouth.

After treatment, it can help to chew food well, drink plenty of fluids with meals, sit upright to eat, raise the head of your bed at night, and avoid troublesome foods such as meat or bread. Cool drinks and simple painkillers can soothe any chest discomfort afterwards.

Surgical treatment

Surgery is usually kept for strictures that don't respond to dilation, or that are caused by cancer. This may involve removing the affected part of your oesophagus.

If long-term acid reflux is the underlying cause, your surgeon might also suggest a separate operation to correct this and help prevent the stricture coming back.

When should I see a doctor?

See your GP if you have any difficulty or pain when swallowing, so the cause can be found and treated. Seek immediate medical care if you:

• Get food stuck in your throat that won't go down
• Can't swallow solids at all
• Accidentally breathe in a piece of food
• Develop severe chest pain.