Strictures
Videos
Overview
A stricture is an abnormal narrowing of a hollow organ. In the upper digestive tract, strictures form most often in the esophagus, at the pylorus (the outlet of the stomach), and in the duodenum. They develop when injury and inflammation heal with scar tissue that contracts and shrinks the channel. The result is difficulty swallowing, food getting stuck, vomiting, or early fullness, depending on where the narrowing is.
Common causes include long-standing acid reflux, peptic ulcers, eosinophilic esophagitis, radiation, caustic injury, and the healing of surgical connections (anastomoses). Most benign strictures can be treated effectively with endoscopic dilation, while the cause — usually reflux or ulcer disease — is treated to keep the stricture from coming back. Strictures that keep recurring may need advanced endoscopic therapy or surgery.
This page is an overview of digestive strictures. For specific situations, see esophageal stricture, stricture after bariatric surgery, and duodenal obstruction.
Causes
Esophageal strictures
- Peptic (reflux) strictures: chronic acid injury from GERD at the lower esophagus; the most common benign esophageal stricture.
- Schatzki rings: thin rings at the junction of the esophagus and stomach that cause episodes of food sticking.
- Eosinophilic esophagitis: allergic inflammation that causes rings and long, narrow segments, especially in younger adults.
- Pill injury, caustic ingestion and radiation.
- After endoscopic treatment such as ablation or resection for Barrett's esophagus.
- Malignant strictures from esophageal cancer, which must always be excluded.
Pyloric and duodenal strictures
- Peptic ulcer disease: repeated ulcers near the pylorus or in the duodenal bulb heal with scarring.
- NSAID injury and H. pylori infection.
- Crohn's disease of the stomach or duodenum.
- Tumors of the stomach, duodenum or pancreas.
Anastomotic strictures
- After surgery such as esophagectomy, gastrectomy or gastric bypass, the connection between two segments can narrow as it heals.
Risk Factors
- Chronic or untreated GERD
- Large hiatal hernia
- History of peptic ulcers, H. pylori or NSAID use
- Smoking, which impairs healing
- Eosinophilic esophagitis or allergic conditions
- Radiation to the chest or abdomen
- Prior foregut or bariatric surgery
Who It Affects
Peptic esophageal strictures are most common in older adults with long-standing reflux. Eosinophilic esophagitis strictures are more common in younger men with allergies. Ulcer-related pyloric and duodenal strictures occur in adults with chronic ulcer disease, and anastomotic strictures occur in patients who have had surgery on the stomach or esophagus.
Complications
- Food impaction requiring emergency endoscopy
- Aspiration into the lungs
- Malnutrition and dehydration
- Perforation, rarely, during impaction or dilation
- Gastric outlet obstruction from pyloric strictures
Symptoms
- Difficulty swallowing solid foods, which slowly progresses
- Food impaction: a bite that will not go down or come back up
- Regurgitation and drooling during episodes
- Heartburn with peptic strictures
- Vomiting, early fullness and bloating with pyloric or duodenal strictures
- Weight loss and avoidance of certain foods
Diagnosis
- Upper endoscopy: shows the stricture, allows biopsies to exclude cancer and eosinophilic esophagitis, and often allows treatment in the same session. See diagnostic upper endoscopy.
- Barium swallow or upper GI series: maps the length and diameter of the narrowing and is especially helpful for long or complex strictures.
- CT scan: for pyloric, duodenal or suspected malignant strictures.
- pH testing: confirms reflux as the underlying cause.
- Manometry: when a motility disorder such as achalasia may be mimicking a stricture.
Differential Diagnosis
- Achalasia and other motility disorders
- Esophageal or gastric cancer
- Eosinophilic esophagitis
- Extrinsic compression from tumors or vessels
- Gastroparesis, which mimics outlet obstruction
Lifestyle Modifications
- Cut food into small pieces and chew thoroughly.
- Drink fluids with meals to help food pass.
- Avoid dry, tough foods such as steak and bread until treated.
- Control reflux: avoid late meals, alcohol and smoking.
- Take pills upright with plenty of water.
- Avoid NSAIDs if you have ulcer-related strictures.
Treatment Options
- Endoscopic dilation: the first-line treatment for benign strictures, using balloons or bougies to gradually stretch the narrowing. Dilation is done in careful increments to limit the risk of perforation (Egan et al., Gastrointestinal Endoscopy, 2006). See esophageal dilation.
- Acid suppression after dilation: proton pump inhibitors reduce the need for repeat dilation of peptic strictures (Smith et al., Gastroenterology, 1994).
- Treat the cause: H. pylori eradication and NSAID avoidance for ulcer strictures; diet or medication for eosinophilic esophagitis.
- Refractory strictures: strictures that cannot be opened to 14 mm within five sessions are considered refractory (Kochman et al., Gastrointestinal Endoscopy, 2005) and may be treated with steroid injection, incisional therapy or temporary stents.
- Anti-reflux surgery: for peptic strictures driven by a large hiatal hernia or severe reflux, fundoplication with hiatal hernia repair removes the cause.
- Surgery for outlet strictures: pyloroplasty or gastrojejunostomy when dilation fails.
When to See a Doctor
See a doctor if food sticks when you swallow, if swallowing is getting harder over time, or if you vomit after meals. Seek emergency care if a bite of food is stuck and you cannot swallow saliva.
When to Seek Treatment
Seek specialist care when a stricture keeps coming back after dilation, when reflux is the cause and remains uncontrolled, or when you are losing weight.
Long-Term Outlook
With the stricture opened and its cause treated, most patients return to a normal diet. Long-term acid control and follow-up endoscopy when symptoms return keep results durable.
Related Reading and Videos
Read more in our articles Endoscopic Management of Complications: What Patients Should Know and Is Bariatric Surgery Safe?. Watch Sleeve Gastrectomy: What Really Happens — Risks, Hormones, Recovery Explained and Why Gastric Bypass Is the Gold Standard — Results, Risks & Life After Surgery on our video library. Related conditions include Peptic Ulcer Disease. Treatments that may be involved include Esophageal Dilation (Endoscopic Balloon & Bougie Dilation for Strictures & Dysphagia), Gastric Bypass Stricture Management and Gastric Sleeve Stricture Management.
More Foregut and Reflux Conditions
Explore related topics in our foregut patient library: Esophageal Ulcer, Peptic Ulcer Disease, Zollinger–Ellison Syndrome, GERD (Acid Reflux), Functional Heartburn and Paraesophageal Hernia.
Prognosis
Most benign strictures respond well to dilation, and many patients need only one to three sessions. Recurrence is more likely when the underlying cause is not controlled. Refractory strictures are uncommon but may need advanced therapy.
Why Choose Dr. de la Cruz‑Muñoz
Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM, is a board-certified surgeon specializing in minimally invasive foregut and bariatric surgery in Miami who directed a bariatric surgery fellowship for 10 years, training 13–14 fellows who also gained experience in foregut surgery. He performs endoscopy and dilation himself and offers anti-reflux and revisional surgery when a stricture keeps coming back. Treating both the narrowing and its cause gives patients a lasting result. Patients traveling from outside South Florida are welcome.
Whatever has caused a stricture, Dr. de la Cruz-Muñoz draws on over 25 years of practice and over 15,000 minimally invasive procedures, including complex foregut, hernia, gallbladder and abdominal operations as well as bariatric surgery.
Featured Procedures
FAQ
All three stretch the esophagus, but they differ in device and purpose (Coronel and Waxman, Yamada's Textbook of Gastroenterology, 2022). A bougie is a smooth, tapered dilator passed across the narrowing (often over a guidewire); because the surgeon can feel the resistance, it allows a controlled, graduated stretch (Singh et al., Surgical Endoscopy, 2023). A through-the-scope balloon is passed through the endoscope, positioned across the narrowing under direct vision, and inflated to a set diameter, delivering outward (radial) pressure (Coronel and Waxman, Yamada's Textbook of Gastroenterology, 2022). For ordinary strictures, balloons and bougies are equally effective and safe (ASGE Standards of Practice Committee, 2012). Pneumatic dilation is different — it uses a much larger balloon (30–40 mm) specifically to forcibly disrupt the lower esophageal sphincter muscle in achalasia or selected EGJOO, and it carries a somewhat higher perforation risk because of this (see our Achalasia and EGJOO pages) (Patel et al., Gastroenterology, 2022). The choice is based on the type, length, and tightness of the narrowing and its underlying cause.
Both narrow the lower esophagus and cause food to stick, but they look and behave differently. A peptic stricture is a smooth, concentric, fixed segment of narrowing — often 1–4 cm long — produced by reflux scarring just above a hiatal hernia; it tends to cause steady, slowly progressive difficulty swallowing solids, usually alongside heartburn (Levine and Rubesin, Abdominal Radiology, 2017; Sethi and Richter, The Esophagus, 2021). A Schatzki ring is a thin, membrane-like band (only 1–4 mm tall) right at the junction of the esophagus and stomach; it typically causes intermittent swallowing trouble and is a common cause of sudden food impaction (Sethi and Richter, The Esophagus, 2021). Ring diameters of 13 mm or less reliably cause symptoms, while rings wider than 20 mm rarely do (Sethi and Richter, The Esophagus, 2021). A Schatzki ring is often seen better on a barium swallow than on endoscopy, and when the two can't be told apart, careful stepwise dilation is used (Pasha et al., ASGE Guideline, 2014). Both respond well to dilation, and both recur less often when reflux is controlled with acid-suppressing medication.
In most cases, yes — acid reflux is the leading cause. Historically about 70% of all benign esophageal strictures were peptic strictures caused by longstanding gastroesophageal reflux disease (Sethi and Richter, The Esophagus, 2021). Repeated acid injury inflames and ulcerates the lining of the lower esophagus; as it heals, the body lays down scar tissue (collagen) that contracts over time and narrows the channel food travels through (Sethi and Richter, The Esophagus, 2021). Peptic strictures develop in roughly 7%–23% of people with untreated erosive esophagitis (Maret-Ouda et al., JAMA, 2020). Even the Schatzki ring — a thin band at the junction of the esophagus and stomach — is strongly linked to reflux, with abnormal acid exposure demonstrated in a large share of patients (Khalaf and Castell, The Esophagus, 2021). That connection is why treatment is never just about stretching the narrowing: controlling the acid is what keeps it from scarring shut again.
An esophageal stricture is a narrowing of the esophagus that makes it hard for food to pass. Most are caused by scarring from long-standing acid reflux (peptic strictures). Other causes include Schatzki rings, eosinophilic esophagitis, pill or caustic injury, radiation, surgical connections and, less often, cancer. The main symptom is gradually worsening difficulty swallowing solid foods. Strictures are diagnosed with endoscopy and treated with dilation, along with treatment of the underlying cause.
