People with and without chronic acid reflux may be at risk of having a esophageal stricture or an esophageal ring. These are two different types of constrictions or narrowing of the esophagus. An esophageal ring manifests as rare episodic difficulty swallowing with solid food getting stuck. The sensation of food getting stuck can occur a couple times a year or may happen only once every few years. It is nonprogressive, meaning that over time swallowing generally does not get worse, and most patients with rings rarely have any symptoms. The classic story is a man who goes out to dinner and has a couple of drinks, and then a piece of steak gets stuck in his esophagus. This is called steakhouse syndrome and is caused by a structural narrowing at the bottom of the esophagus that interferes with swallowing for someone who has had a few drinks and is eating quickly or not chewing the food enough. Thus, a larger than normal swallowed piece of meat becomes stuck above the ring. This is an extremely uncomfortable situation: symptoms are mild chest pain, inability to swallow even saliva, and vomiting or regurgitation.
Sometimes with fluids the food passes, but frequently the person has to vomit the food to clear the blockage. If this does not work, then the person needs to go to the emergency room. Occasionally, medications can be taken to relax the esophagus so food can pass, but this usually does not work. Frequently, an emergent endoscopy test needs to be done to either remove the food or push it down into the stomach.
There is some debate in the medical literature as to whether esophageal rings are caused by chronic acid damage or whether people are born with them (congenital esophageal narrowing). Rings can easily be treated at the time of endoscopy. Rings generally occur at the bottom of the esophagus and at the top of a hiatal hernia where the lining of the esophagus and stomach meet. Local esophagitis or acid damage is not uncommon. Rings are very short and are composed of the superficial lining or mucosa of the esophagus. Esophageal rings are very common and do not always cause difficulty swallowing. If I endoscope a patient without a history of difficulty swallowing and I see a ring, I generally leave it alone. Rings are a benign process and do not get worse, cause esophagitis, or result in Barrett’s esophagus or cancer.
An esophageal stricture is a different kind of esophageal narrowing. Strictures generally do get worse with minor difficulty swallowing solids that may progress to extreme difficulty with solids or, rarely, solids and liquids. Strictures are usually benign and result from chronic acid damage to the esophagus that causes the formation of scarring and contraction of the esophagus. Rarely, a stricture can be caused by cancer. Barium studies can diagnose a stricture but may not be able to tell whether it is benign or malignant, and frequently an endoscopy is needed to make the ultimate diagnosis.
Because strictures are caused by inflammation and chronic acid damage, they are longer and involve more of the esophagus than rings do. Strictures are scarring of not only the lining but also the wall of the esophagus. To allow healing they require more potent medication such as a PPI, which takes away the underlying cause of the stricture and allows the inflammation to resolve. Strictures are also treated at the time of endoscopy by stretching or dilating the esophagus. Some strictures can be very difficult to treat and can require repeat dilations.
In addition to acid damage, some of the most difficult strictures can be caused by some medications (see table 2). Pills may get stuck in the esophagus because they were taken dry or with inadequate water or because of a ring.When the pill sits there, it can burn, irritate, or ulcerate the esophagus, known as a pill ulcer. Certain medications taken on a regular basis allow this process to happen repeatedly, resulting in scarring and a stricture.
By Mortin - Copyright 2009
Last modification 31/12/2009
What is an Esophageal Stricture or Esophageal Ring? References