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Esophageal stricture

What's new

A newly published guideline developed by an international multidisciplinary panel addresses the management of esophageal strictures in patients with epidermolysis bullosa. Recommended diagnostic investigations include esophagogram and video-fluoroscopy, with thorough assessment of the entire esophagus, particularly the cervical segment. Endoscopy is not recommended for diagnosis. Preventive measures include early referral to a dietitian and dentist, topical treatment of oral lesions, application of fluoride-containing products to teeth (with systemic supplementation if needed), use of oral viscous budesonide, and treatment of gastroesophageal reflux disease. Stricture management includes esophageal dilation, with gastrostomy when indicated. Fluoroscopically-guided balloon dilation is the preferred first-line technique, while bougie (semi-rigid) dilation should be avoided. .

Background

Overview

Definition
Esophageal stricture is a chronic condition characterized by dysphagia due to esophageal inflammation, collagen deposition and scar tissue.
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Pathophysiology
Esophageal stricture is caused mainly by GERD, esophagitis, tumors (adenocarcinoma, SCC), corrosive injury to the esophagus, intrinsic/extrinsic compressions, Plummer-Vinson syndrome, postsurgical complications, and congenital defects.
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Disease course
Clinical manifestations of an esophageal stricture include dysphagia, gastroesophageal reflux, vomiting, chest pain, cough, hoarseness, gastrointestinal bleeding, anemia, and weight loss. There is an increased risk of recurrence after initial dilatation.
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Prognosis and risk of recurrence
In-hospital mortality in benign and malignant esophageal strictures is 1.4% and 3.1%, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of esophageal stricture are prepared by our editorial team based on guidelines from the International Multidisciplinary Panel on Epidermolysis Bullosa (EB-IMP 2025), the European Society of Gastrointestinal Endoscopy (ESGE 2021), the American College of Radiology (ACR 2019), the World Society of Emergency Surgery (WSES 2019), the British Society of Gastroenterology (BSG ...
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Diagnostic investigations

History and physical examination
As per CAG 2018 guidelines:
Elicit a history to help differentiate between structural and motility disorders of the esophagus in patients with suspected esophageal dysphagia.
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Assess for alarm features requiring urgent investigations in patients with esophageal dysphagia to ensure timely referral for appropriate management.
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  • Barium esophagram

  • CT

  • Upper gastrointestinal endoscopy

Diagnostic procedures

Esophageal biopsy: as per BSG 2018 guidelines, obtain biopsy specimens from all strictures for histological analysis to exclude malignancy and eosinophilic esophagitis.
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Medical management

Acid-reducing therapy: as per BSG 2018 guidelines, initiate PPI therapy in patients with GERD and dysphagia to reduce the need for esophageal dilation.
A
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Therapeutic procedures

Endoscopic dilation, indications: as per ASGE 2014 guidelines, perform endoscopic dilation in patients with dysphagia secondary to benign intrinsic strictures of the esophagus.
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  • Endoscopic dilation (patient selection and preparation)

  • Endoscopic dilation (preprocedural counseling)

  • Endoscopic dilation (personnel and setting requirements)

  • Endoscopic dilation (technical considerations)

  • Endoscopic dilation (postprocedural assessment)

  • Endoscopic dilation (refractory strictures)

  • Esophageal stent placement (indications)

  • Esophageal stent placement (technical considerations)

  • Intralesional corticosteroid injections

  • Self-bougienage

Surgical interventions

Indications for surgery: as per ESGE 2021 guidelines, consider offering alternative treatment strategies, such surgical treatment, in patients with refractory benign esophageal strictures that have not satisfactorily improved after two separate treatments with temporary stenting.
C
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Specific circumstances

Patients with malignant disease: as per ESGE 2021 guidelines, perform placement of partially or fully covered self-expandable metal stents for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.
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  • Patients with Schatzki ring (PPIs)

  • Patients with Schatzki ring (endoscopic dilation)

  • Patients with Schatzki ring (surgical incision)

  • Patients with postoperative strictures

  • Patients with post-endoscopic strictures

  • Patients with post-radiation strictures

  • Patients with caustic strictures (evaluation)

  • Patients with caustic strictures (esophageal dilation)

  • Patients with caustic strictures (reconstructive surgery)

  • Patients with eosinophilic esophagitis

  • Patients with epidermolysis bullosa (evaluation)

  • Patients with epidermolysis bullosa (primary prophylaxis and early detection)

  • Patients with epidermolysis bullosa (esophageal dilation)

  • Patients with epidermolysis bullosa (secondary prophylaxis)