Benign oesophageal stricture from long-standing reflux
A benign peptic (acid-related) oesophageal stricture from long-standing acid reflux is a fixed narrowing of the oesophagus by scar tissue, left when the inflammation heals by fibrosis.
Remember
Long-standing acid reflux inflammation can heal by fibrosis, and the scar can narrow the lumen, causing progressive dysphagia (difficulty swallowing) that is worse for solids than for liquids. Treat a benign oesophageal stricture by suppressing acid to stop further injury and by dilating the narrowed segment.
Memory aid
treating the fire, then unblocking the pipe
Stopping the acid injury is treating the fire, and widening the narrowed lumen is unblocking the pipe.
In gastro-oesophageal reflux disease (GORD), acid repeatedly washes over the lining of the lower oesophagus and can cause oesophagitis, which means inflammation of the oesophagus. When that inflammation is severe or long-standing, the wall heals by fibrosis, which means scar tissue made of collagen.
Scar tissue is stiff and shrinks as it matures, so the lumen (the channel inside the oesophagus) becomes narrower and forms a stricture. The stricture is benign, meaning it is not cancer. Because the stricture is a fixed narrowing (one that does not come and go), it causes dysphagia (difficulty swallowing) that is gradually progressive, typically for solid foods such as bread or meat. Soft food and liquids are affected later. Oesophageal spasm, unlike a stricture, comes and goes. A patient may avoid eating and lose weight.
Long-standing reflux is the usual cause, so it needs controlling. Another cause, such as radiation-induced fibrosis, is less common. Because cancer can also narrow the oesophagus, anyone who has new dysphagia needs an endoscopy to make sure.
Management has two jobs. First, treat the cause: lifestyle measures and a proton pump inhibitor (a drug that blocks the acid-producing pumps in the stomach lining) stop further acid injury. Second, widen the lumen with endoscopic dilation, where a balloon or dilator is passed through the narrowing and stretches it open. Dilation often has to be repeated, because scar tissue tends to tighten again.
Key facts
- Mechanism
- long-standing acid reflux can cause oesophagitis, which can heal by fibrosis (scar tissue made of collagen) and narrow the lumen.
- Pattern
- the narrowing is fixed (it does not come and go), so dysphagia is gradually progressive, typically for solids, unlike oesophageal spasm, which comes and goes.
- Usual cause
- acid reflux is the usual cause of a benign oesophageal stricture, and radiation-induced fibrosis is a less common cause.
- New dysphagia
- anyone who has new dysphagia needs an endoscopy, because cancer can also narrow the oesophagus.
- Direct treatment
- endoscopic dilation stretches the scar with a balloon or graduated dilator, and it is often repeated.
- Alongside dilation
- a proton pump inhibitor treats the cause by stopping further acid injury.
Exam traps
- Barrett's oesophagus (a change in the type of cell lining the oesophagus after prolonged acid exposure) does not explain the stricture, because it is a change in the lining and not scar tissue, and it does not itself narrow the lumen.
- Failure of the lower oesophageal sphincter barrier does not itself narrow the oesophagus, because it explains why acid reflux occurs, while the stricture is the downstream result of acid injury and scarring.
- A proton pump inhibitor alone does not treat the narrowing, because it reduces further acid injury but does not widen the existing scar, so the patient would still have dysphagia.
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