Managing swallowing difficulties: effective treatments for oesophageal strictures

An oesophageal stricture can make swallowing very difficult or uncomfortable. In this article, a talented endoscopist and consultant gastroenterologist explains this condition, and how patients can feel relief.

What is an oesophageal stricture?

An oesophageal stricture is the abnormal narrowing of the oesophagus, which is the tube that food and liquids run through from the mouth down to the stomach. During stricture, the oesophagus becomes constricted for what could be due to a variety of reasons, obstructing the mechanism of swallowing.

Oesophageal strictures are likely to be symptomatic of underlying conditions or diseases, and the narrowing can either stem from within the oesophagus, or from the outside.

When occurring internally, the lining of the oesophagus, called the mucosa, swells or stiffens, and becomes unable to stretch when swallowing. External causes of narrowing could be due to increasing pressure from neighbouring organs (like the lungs, for example), or growths like tumours.

Oesophageal strictures are to be treated quite urgently due to their impact on swallowing, which humans need in order to eat and drink, and because strictures are likely to worsen over time.

As strictures develop over a period, the symptoms can be quite gradual. Patients will first note that swallowing becomes a bit difficult and may compensate by eating smaller bits of food and chewing more to break down the pieces. As the stricture progresses, patients will feel as though there is a lump in their throat and that their throat muscles aren’t working normally.

They may also experience chest pain, which is not related to the heart or the lungs, but because the oesophagus is constricting, coughing or choking when trying to swallow, food coming back up after trying to swallow (regurgitation), and even unexpected weight loss due to unintentionally eating less food.

What causes oesophageal strictures?

Most strictures are due to gastroenterological reflux disease (GERD), where the stomach acid habitually flows backwards and up the oesophagus. This corrosive liquid irritates that mucosa, causing inflammation and swelling. Too much exposure to the acid, and the mucosa can even develop scar tissue, which will cause permanent narrowing of the oesophagus.

Other causes of internal inflammation include:

• Pill oesophagitis, where overconsumption of certain medications, like nonsteroidal anti-inflammatory drugs (NSAIDS) or potassium supplements, erode the oesophageal lining.
• Infectious oesophagitis, where viruses like HPV or fungal infections can cause the immune system to inflame the oesophagus as a retaliatory response against pathogens.
• Eosinophilic oesophagitis, a rare autoimmune disease.
• Swallowing something caustic, corrosive, or very hot.
• Cancer treatments like radiation therapy.

Oesophageal cancer is rare but can also cause strictures, due to abnormal cancer cell growth leading to overcrowding in the oesophagus. This kind of cancer is very rapid to progress, so patients who suddenly and markedly develop an oesophageal stricture should seek medical advice urgently. Oesophageal cancer is highly related to chronic oesophagitis and GERD, due to persistent stimulation to the oesophageal cells triggering a response.

How is an oesophageal stricture diagnosed?

One of the initial tests done to diagnose general oesophageal disorders is a type of X-ray called an oesophagram, where the patients swallow a substance called barium, and an X-ray records the act to see how the substance moves through the oesophagus.

Another procedure would be the upper endoscopy, for which the patient is sedated and the endoscopist feeds the endoscope, a flexible tube with a camera and light at the end that allows the endoscopist to see the inside of the oesophagus in sharp detail, accurate colour, and real-time. If necessary, the endoscopist can also take a sample of tissue during this in what is called a biopsy for further testing.

How is an oesophageal stricture treated?

The main priority when treating oesphageal strictures is to regain space in the oesophagus. The majority of strictures can be treated with a dilation procedure, where the oesophageal tube is widened with the insertion of a balloon or stent, which will increase in diameter gradually over the course of a few weeks, with the patient returning to the clinic to receive to treatment periodically. However, this is only effective for strictures that are in a small portion of the oesophagus and not too constricted; more complex conditions, like injury or cancer, will need a different treatment approach. Oesophageal cancer, for example, will focus more on treating the cancer and removing or destroying the aberrant cells

In select cases, steroid injections can be used to reduce inflammation and prevent reoccurrences of the narrowing.

For scar tissue that is causing stricture patients may be recommended to undergo endoscopic stricturoplasty, which uses the endoscopic technique, to apply electrical bursts of energy to excise scar tissue. This procedure may take several sessions.

Used in the direst of cases where more conservative treatments were not effective, an oesophagectomy is a surgery to remove a portion or all of the oesophagus. This procedure may be employed for patients with GERD.