Esophageal Stricture : Definition : Etiology / Causes: Clinical Manifestations : Diagnostic Studies: Management : Nursing Care Plan : Health Education :

 

Esophageal Stricture

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Definition

An esophageal stricture is a narrowing of the esophagus that leads to difficulty in swallowing (dysphagia). It is often caused by chronic gastroesophageal reflux disease (GERD), esophagitis, prolonged nasogastric intubation, ingestion of caustic substances, or tumors.

Etiology / Causes

  1. Chronic GERD → Acid reflux leads to inflammation and scar tissue formation.
  2. Esophageal injury → From caustic ingestion (acids/alkalis).
  3. Iatrogenic causes → Post-surgical or after radiation therapy.
  4. Tumors → Esophageal cancer.
  5. Other → Infection, autoimmune disease.

Pathophysiology:

The narrowing of the esophagus is typically caused by inflammation, scarring, or tumor growth. Chronic inflammation, such as that seen in severe GERD, can lead to the formation of scar tissue. This scar tissue contracts over time, reducing the lumen of the esophagus. This reduction impedes the passage of food and liquids, leading to dysphagia.

Clinical Manifestations

  • Progressive dysphagia (first solids, then liquids).
  • Odynophagia (painful swallowing).
  • Regurgitation of food or liquids.
  • Unintentional weight loss and malnutrition.
  • Aspiration → coughing, choking.
  • Chest discomfort or fullness.
  • Weight loss: Due to decreased oral intake.
  • Choking or coughing: During meals.

Diagnostic Studies:

  • Barium Swallow Study (Esophagram): Visualizes the stricture and its extent.
  • Upper Endoscopy (EGD) with Biopsy: Directly visualizes the stricture, allows for dilation, and tissue biopsy to rule out malignancy or identify the cause of inflammation.
  • Esophageal Manometry: Measures esophageal muscle function and helps rule out motility disorders.
  • pH Monitoring: If GERD is suspected as the cause.
  • CT/MRI if malignancy is suspected.

Management

  1. Medical / Non-surgical
    • Proton Pump Inhibitors (PPIs) for GERD.
    • Corticosteroids (in caustic injuries to reduce inflammation).
    • Nutritional support (soft diet, NG tube, or PEG feeding if severe).
  2. Surgical / Procedural
    • Esophageal dilation (bougie or balloon).
    • Stent placement in malignant strictures.
    • Esophagectomy in severe, refractory cases.

Nursing Care Plan for Esophageal Stricture

1. Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to difficulty swallowing (dysphagia) and reduced oral intake.

Expected Outcomes:

  • Patient will maintain current weight or demonstrate gradual weight gain.
  • Patient will report improved ability to swallow with less discomfort.
  • Patient will consume adequate nutrients as evidenced by laboratory values (albumin, prealbumin, electrolytes) within normal limits.

Nursing Interventions:

  • Assessment:
    • Monitor weight daily/weekly and compare to baseline.
    • Assess dietary intake, calorie count, and food preferences.
    • Evaluate the severity of dysphagia (e.g., ability to swallow liquids, soft foods, solids).
    • Monitor laboratory values (albumin, prealbumin, total protein, electrolytes).
    • Assess for signs of dehydration (poor skin turgor, dry mucous membranes, concentrated urine).
  • Intervention:
    • Dietary Modifications:
      • Provide small, frequent meals with soft, pureed, or liquid consistency as tolerated.
      • Offer high-calorie, high-protein supplements (e.g., Boost, Ensure).
      • Instruct patient to eat slowly, take small bites, and chew thoroughly.
      • Encourage upright positioning during and after meals (at least 30-60 minutes).
      • Avoid foods that may worsen symptoms (e.g., spicy, acidic, very hot/cold foods).
    • Hydration:
      • Provide adequate fluids between meals to avoid feeling full with liquids during meals.
      • Offer thickened liquids if necessary.
      • Monitor fluid intake and output.
    • Medication Administration:
      • Administer proton pump inhibitors (PPIs) or H2 receptor blockers as prescribed to reduce acid production if GERD is a contributing factor.
      • Provide pain medication before meals if odynophagia is significant.
    • Patient Education:
      • Teach swallowing techniques (e.g., chin tuck).
      • Educate on the importance of dietary modifications and supplements.
      • Discuss signs of aspiration and when to seek immediate medical attention.
    • Collaboration:
      • Consult with a dietitian for individualized meal planning.
      • Consult with a speech-language pathologist for swallowing evaluations and therapy.
      • Prepare for possible enteral feeding (NG, G-tube) or parenteral nutrition if oral intake remains insufficient.

2. Nursing Diagnosis: Risk for Aspiration related to impaired swallowing, regurgitation, and esophageal narrowing.

Expected Outcomes:

  • Patient will not experience aspiration, as evidenced by clear lung sounds, absence of coughing/choking during meals, and normal oxygen saturation.
  • Patient will demonstrate proper swallowing techniques.

Nursing Interventions:

  • Assessment:
    • Assess lung sounds regularly for crackles or wheezes, indicating aspiration.
    • Monitor oxygen saturation.
    • Observe for coughing, choking, or gagging during oral intake.
    • Assess the patient's level of consciousness and ability to cooperate with feeding instructions.
  • Intervention:
    • Positioning:
      • Maintain upright position (at least 45-90 degrees) during and for 30-60 minutes after meals.
      • Elevate the head of the bed even when resting.
    • Feeding Techniques:
      • Provide supervision during meals.
      • Ensure a calm and unhurried environment for eating.
      • Encourage small, frequent bites/sips.
      • Instruct patient to chew food thoroughly and swallow completely before taking another bite.
      • Thicken liquids as recommended by the speech-language pathologist.
    • Oral Hygiene:
      • Perform meticulous oral care before and after meals to reduce bacterial load in the mouth.
    • Monitoring:
      • Monitor for signs of respiratory distress (tachypnea, dyspnea, cyanosis).
      • Be prepared to suction if necessary.
    • Patient Education:
      • Educate family and patient on aspiration precautions.
      • Instruct on warning signs of aspiration (e.g., sudden cough, voice change, shortness of breath).
    • Collaboration:
      • Work closely with the speech-language pathologist for dysphagia therapy.

3. Nursing Diagnosis: Acute Pain related to esophageal inflammation, spasm, or diagnostic/therapeutic procedures (e.g., endoscopy, dilation).

Expected Outcomes:

  • Patient will report pain reduction to a tolerable level (e.g., ≤3 on a 0-10 scale).
  • Patient will demonstrate non-pharmacological pain relief methods.
  • Patient will verbalize understanding of pain management strategies.

Nursing Interventions:

  • Assessment:
    • Assess pain characteristics (location, intensity, quality, duration) using a pain scale.
    • Identify aggravating and alleviating factors (e.g., eating, specific foods).
    • Observe non-verbal cues of pain (grimacing, guarding, restlessness).
    • Assess for odynophagia (painful swallowing).
  • Intervention:
    • Pharmacological Management:
      • Administer prescribed analgesics (e.g., acetaminophen, NSAIDs) as needed.
      • Administer viscous lidocaine or topical anesthetics before meals if ordered to alleviate odynophagia.
      • Administer antacids or acid-suppressing medications (PPIs/H2 blockers) to reduce irritation if GERD is contributing to pain.
    • Non-Pharmacological Management:
      • Provide comfort measures (e.g., warm compresses to the chest/throat if tolerated, soothing environment).
      • Encourage relaxation techniques (deep breathing, guided imagery).
      • Offer small sips of cool water or ice chips for soothing effect.
    • Post-Procedure Care:
      • Monitor for post-procedure pain following endoscopy or esophageal dilation.
      • Assess for complications like perforation (severe chest pain, fever, subcutaneous emphysema).
    • Patient Education:
      • Teach patient to report pain promptly.
      • Educate on proper use of pain medications.
      • Discuss the role of diet in pain management.

4. Nursing Diagnosis: Deficient Knowledge related to disease process, treatment regimen, and potential complications.

Expected Outcomes:

  • Patient/family will verbalize understanding of esophageal stricture, its causes, and management.
  • Patient/family will demonstrate proper techniques for dietary modifications and medication administration.
  • Patient/family will identify signs and symptoms requiring immediate medical attention.

Nursing Interventions:

  • Assessment:
    • Assess the patient's current knowledge level regarding their condition and treatment.
    • Identify learning barriers (e.g., anxiety, pain, cognitive impairment).
    • Determine preferred learning style.
  • Intervention:
    • Education on Disease Process:
      • Explain the anatomy and physiology of the esophagus and how the stricture affects it.
      • Discuss the causes of the stricture (e.g., GERD, radiation, injury).
    • Education on Treatment Regimen:
      • Explain all prescribed medications (purpose, dose, side effects, administration).
      • Provide detailed instructions on dietary modifications, including food consistency, meal frequency, and upright positioning.
      • Describe the purpose and procedure for esophageal dilation, if applicable, including pre/post-procedure care and potential complications.
      • If surgical intervention is planned, explain the procedure and recovery.
    • Warning Signs & Complications:
      • Educate on signs of recurrence or worsening stricture (e.g., increasing dysphagia, weight loss).
      • Instruct on signs of aspiration, perforation (after dilation), and infection.
      • Emphasize when to contact the healthcare provider immediately.
    • Lifestyle Modifications:
      • Teach about lifestyle changes that can reduce GERD symptoms (if applicable): avoiding trigger foods, weight management, smoking cessation, limiting alcohol.
    • Resources:
      • Provide written materials, reputable websites, and support group information.
      • Arrange for follow-up appointments and consultations with specialists.
  • Collaboration:
    • Involve family members or caregivers in the teaching process.
    • Coordinate with physicians, dietitians, and speech-language pathologists for consistent education.

5. Nursing Diagnosis: Anxiety related to fear of choking, pain, weight loss, and uncertainty about prognosis.

Expected Outcomes:

  • Patient will verbalize feelings of anxiety and identify coping mechanisms.
  • Patient will demonstrate reduced anxiety levels (e.g., calm demeanor, improved sleep, stable vital signs).
  • Patient will participate in care decisions and express realistic expectations.

Nursing Interventions:

  • Assessment:
    • Assess the patient's level of anxiety using a standardized scale or by observing behaviors (restlessness, agitation, difficulty sleeping).
    • Identify specific fears and concerns.
    • Evaluate the patient's coping strategies and support system.
  • Intervention:
    • Therapeutic Communication:
      • Listen actively and empathetically to the patient's concerns.
      • Provide clear, honest, and consistent information about the condition and treatment.
      • Reassure the patient that choking and pain are being actively managed.
    • Environmental Management:
      • Create a calm, quiet, and supportive environment.
      • Encourage the presence of supportive family or friends.
    • Coping Strategies:
      • Teach relaxation techniques (e.g., deep breathing, progressive muscle relaxation, meditation).
      • Encourage diversional activities (reading, listening to music).
      • Discuss the importance of stress reduction.
    • Empowerment:
      • Involve the patient in decision-making regarding their care whenever possible.
      • Encourage setting small, achievable goals related to eating or managing symptoms.
    • Medication:
      • Administer anxiolytics as prescribed if anxiety is severe and interfering with care.
  • Collaboration:
    • Refer to social work or spiritual care as appropriate.
    • Consider a psychiatric consultation if anxiety or depression is profound.

Nursing Care Plan for Esophageal Stricture

Nursing Diagnosis

Goals / Outcomes

Nursing Interventions

Rationale

Evaluation

Impaired Swallowing related to narrowing of the esophagus

Patient will swallow safely without choking/aspiration

- Assess swallowing ability and degree of dysphagia
- Provide small, frequent, soft or semi-solid meals
- Encourage upright position during and after meals
- Collaborate with dietitian

Prevents aspiration and ensures adequate nutrition

Patient eats without aspiration or choking

Risk for Aspiration related to regurgitation of food/liquid

Patient will maintain patent airway without signs of aspiration

- Place patient in Fowler’s or high Fowler’s position while eating
- Instruct to eat slowly, chew thoroughly
- Suction equipment at bedside
- Educate on aspiration precautions

Upright position reduces reflux; suction ensures prompt airway clearance

Patient remains free from aspiration episodes

Imbalanced Nutrition: Less than body requirements related to dysphagia

Patient will maintain or gain weight, and meet nutritional requirements

- Monitor weight and nutritional intake
- Provide high-calorie, high-protein diet
- Offer liquid supplements
- If severe, prepare for enteral feeding support

Promotes adequate nutrition and prevents weight loss

Patient maintains stable weight and shows improved nutritional status

Acute Pain (odynophagia) related to inflammation

Patient will report reduced pain while swallowing

- Assess pain characteristics
- Administer analgesics or topical anesthetics as prescribed
- Encourage warm liquids (if tolerated)
- Administer PPIs or antacids

Reduces discomfort and prevents worsening of esophageal injury

Patient reports reduced pain during swallowing

Anxiety related to difficulty in swallowing and fear of choking

Patient will verbalize reduced anxiety and demonstrate coping mechanisms

- Provide reassurance and explain procedures
- Encourage expression of fears
- Provide relaxation techniques
- Involve family in care

Reduces stress and improves cooperation with care plan

Patient verbalizes decreased anxiety

Health Education / Discharge Instructions

  • Eat small, frequent, soft meals; avoid spicy, acidic, or hard-to-swallow foods.
  • Sit upright during and at least 30–60 minutes after meals.
  • Avoid alcohol, smoking, and caffeine (increase reflux).
  • Take prescribed medications (PPIs, pain relief) regularly.
  • Report worsening dysphagia, weight loss, vomiting blood, or chest pain.
  • Follow-up for endoscopic dilation or other procedures as advised.

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