Esophagitis & Strictures
- Esophagitis is an inflamed, angry esophagus; a stricture is the scar tissue that narrows the tube after the inflammation has done its damage.
- The barium swallow is the classic way to see the shape of the lumen — endoscopy sees the lining, but fluoroscopy shows you the whole pipe in motion.
- The big clue is narrowing: smooth and tapered usually means benign (reflux, scarring); abrupt, shouldered, or irregular narrowing should make you worry about cancer.
- Where the narrowing sits and how long it is are your best hints to the cause — distal smooth strictures love reflux; mid-esophageal webs and longer strictures point elsewhere.
Think of the esophagus as a soft garden hose running from your throat to your stomach. Most of the time it just quietly delivers lunch and asks for nothing. But if you keep splashing acid up into it, or scrape it with the wrong pill, or radiate it, the hose gets irritated, then inflamed, and eventually — if the irritation keeps going — it heals the only way scar tissue knows how: by getting tight and stiff. That tight spot is the stricture, and it's why someone shows up saying "food is getting stuck."
Esophagitis: the inflamed phase
Esophagitis just means the esophagus is inflamed and unhappy. The most common culprit by far is gastroesophageal reflux — acid sloshing back up where it doesn't belong, usually hitting the distal esophagus first because that's the part closest to the stomach's splash zone.
There are other flavors worth knowing, because they like different neighborhoods of the tube:
| Cause | Where it tends to hit | A telling clue |
|---|---|---|
| Reflux | Distal esophagus | Most common; sets up distal strictures over time |
| Infection (e.g. Candida, herpes, CMV) | Anywhere, often diffuse | Seen in immunocompromised patients |
| Pill-induced | Mid-esophagus, near the aortic arch | Pills lingering where the tube is naturally squeezed |
| Caustic ingestion | Long segments | Swallowed something corrosive; can scar badly |
| Radiation | Within the treated field | Follows the radiation port, not anatomy |
On a barium swallow, acute inflammation can look like a finely irregular or granular mucosa, sometimes with shallow ulcers — the lining loses its normal smooth, satiny look. Honestly, early esophagitis is often better felt by the patient and seen by the endoscope than appreciated on fluoroscopy. The radiologist's moment to shine comes later, when scarring sets in.
Strictures: the scarred phase
A stricture is what you get when inflammation overstays its welcome. The wall fibroses, the lumen narrows, and the patient develops dysphagia — trouble swallowing, classically for solids first (a steak is harder to squeeze through a narrow pipe than a milkshake).
On a barium study, the job is to describe the narrowing carefully, because its character is what separates "probably benign scar" from "get a biopsy." A benign peptic stricture from chronic reflux is usually smooth, tapered, and in the distal esophagus, often sitting just above a hiatal hernia like a punctuation mark at the end of the reflux story.
A smooth, gradually tapering distal narrowing in someone with years of heartburn is the textbook benign peptic stricture. The transition from normal tube to narrow tube is gentle — like a funnel, not a cliff.
The narrowing you must not wave through
Here's the part where the garden hose analogy earns its keep. A benign stricture is like a hose that got crimped slowly and evenly. A malignant one is like a hose with a hard lump growing into it from the wall — the narrowing is abrupt, irregular, and the edges look shouldered, as if the lumen hits a wall.
Do not assume a stricture is benign just because the patient has reflux. An irregular, abruptly narrowed, or asymmetric stricture — especially with shelf-like "shouldered" margins or a longer segment — can be esophageal cancer hiding behind dysphagia. When the appearance isn't reassuringly smooth, the answer is endoscopy and biopsy, not optimism.
A quick mental sorting tool:
| Feature | Leans benign | Leans malignant |
|---|---|---|
| Contour | Smooth, tapered | Irregular, nodular |
| Transition | Gradual | Abrupt, shouldered |
| Length | Short | Often longer |
| Symmetry | Symmetric | Asymmetric |
These are tendencies, not guarantees — real esophagi don't read the textbook. Any stricture that looks even mildly suspicious gets a scope.
How we actually look
The workhorse here is the barium swallow (esophagram), a fluoroscopic study where the patient drinks contrast and we watch it travel down in real time. It shows the lumen's shape, where it narrows, and how the tube moves. The choice of contrast matters — if there's any concern for a leak or perforation, we reach for water-soluble contrast instead of barium, a tradeoff covered in barium vs water-soluble GI contrast.
A stricture is a fixed narrowing — it's there whether the esophagus is squeezing or not. That's different from a motility problem, where the tube is the right width but the muscle coordination is off. If the lumen looks fine but swallowing still fails, think achalasia and motility disorders instead.
The one thing to carry out the door
Esophagitis is the inflamed beginning; a stricture is the scarred end. Your single most useful skill on the barium swallow is reading the character of the narrowing: smooth and tapered reassures, but abrupt, irregular, or shouldered narrowing is a red flag that earns a scope and a biopsy — because that's where cancer hides.