Strictures

A localized narrowing of the esophagus.

Persons with long-standing gastroesophageal reflux disease can develop strictures in the distal esophagus due to acid reflux.

Symptoms, Signs, and Diagnosis

Elderly persons are at risk of developing drug- or injury-induced strictures because they are exposed to irritating drugs, may spend more time in the recumbent position, and are more likely to have motility or anatomic disorders of the esophagus. A wide variety of drugs have been implicated, including doxycycline, tetracycline, clindamycin, emepronium bromide, potassium, iron, alprenolol, quinidine, acetylsalicylic acid, theophylline, nonsteroidal anti-inflammatory drugs (NSAIDs), and alendronate. Injury-induced strictures may result from swallowing caustic (acidic or alkaline) agents. Progressive dysphagia for solids develops. Weight loss rarely occurs in persons with benign strictures, because these persons frequently maintain their good appetites and may alter their diets to include foods and beverages that do not cause symptoms.

Clinical history can suggest the diagnosis. Barium swallow can show clustered ulcers or a stricture of the esophagus, typically at the level of the gastroesophageal junction. The stricture is typically smooth, tapered, and of varying length. An upper endoscopy can show pill fragments and superficial or deep ulcerations with heaped up margins.

An upper endoscopy with biopsy should be performed to exclude Barrett's esophagus (premalignant, metaplastic columnar epithelium in the distal esophagus) or a malignancy.

Treatment

Treatment is aimed at reducing symptoms; acid suppression with proton pump inhibitors reduces concurrent gastric acid-induced injury. Dilatation (with pneumatic or other types of dilator) should be considered, although drug-induced strictures can be difficult to dilate and may require multiple sessions. Occasionally, antireflux surgery is required.