Withdrawal of ranitidine

In April 2020, the Food and Drug Administration (FDA) requested that all forms of prescription and over-the-counter (OTC) ranitidine (Zantac) be removed from the U.S. market. This recommendation was made because unacceptable levels of NDMA, a probable carcinogen (cancer-causing chemical), were found in some ranitidine products. If you’re prescribed ranitidine, talk with your doctor about safe alternative options before stopping the drug. If you’re taking OTC ranitidine, stop taking the drug and talk with your healthcare professional about alternative options. Instead of taking unused ranitidine products to a drug take-back site, dispose of them according to the product’s instructions or by following the FDA’s guidance.

Ranitidine, brand name Zantac, is now marketed as Zantac 360, which contains a different active ingredient (famotidine). Famotidine is in the same class as ranitidine and works the same way but hasn’t been found to contain unacceptable levels of NDMA.

Benign esophageal stricture means the inside of your esophagus has become too narrow. It’s usually caused by damage from stomach acid flowing back up into your esophagus.

Benign esophageal stricture describes a narrowing or tightening of the esophagus. The esophagus is the tube that brings food and liquids from your mouth to your stomach. “Benign” means it’s not cancerous.

Benign esophageal stricture typically occurs when stomach acid and other irritants damage the lining of the esophagus over time. This leads to inflammation (esophagitis) and scar tissue, which causes the esophagus to narrow.

Although benign esophageal stricture isn’t a sign of cancer, the condition can cause several problems. Narrowing of the esophagus may make it difficult to swallow. This increases the risk of choking. It can also lead to complete obstruction of the esophagus. This can prevent food and fluids from reaching your stomach.

Benign esophageal stricture can happen when scar tissue forms in your esophagus. This is often the result of damage to the esophagus. The most common cause of damage is gastroesophageal reflux disease (GERD), also known as acid reflux.

GERD occurs when the lower esophageal sphincter (LES) doesn’t close or tighten properly. The LES is the muscle between your esophagus and your stomach. It normally opens for a short amount of time when you swallow.

Stomach acid can flow back up into the esophagus when it doesn’t close completely. This can create a burning sensation in the lower chest known as heartburn.

Frequent exposure to harmful stomach acid can cause scar tissue to form. Eventually, the esophagus can narrow. About 70% to 80% of the time, GERD is the underlying cause of benign esophageal stricture in adults.

Other causes of benign esophageal stricture include:

  • radiation therapy to your chest or neck
  • accidental swallowing of an acidic or corrosive substance (such as batteries or household cleaners)
  • extended use of a nasogastric tube, a special tube that carries food and medicine to your stomach through your nose
  • esophageal damage caused by an endoscope (a thin, flexible tube used to look inside a body cavity or organ)
  • long-term use of medications that can cause inflammation in your esophagus, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and tetracyline antibiotics
  • treatment of esophageal varices, which are enlarged veins in the esophagus that can rupture and cause severe bleeding
  • eosinophilic esophagitis, a long-term (chronic) allergic condition that causes inflammation in the esophagus

Typical symptoms of benign esophageal stricture include:

Dense and solid foods can lodge in the esophagus when it narrows. This may cause choking or difficulty breathing.

Problems swallowing can prevent you from getting enough food and liquid. This may lead to dehydration and malnutrition.

There’s also a risk of getting pulmonary aspiration, which occurs when vomit, food, or fluids enter your lungs. This could result in aspiration pneumonia, an infection caused by bacteria growing around the food, vomit, or fluids in the lung.

It’s also possible for a hole to develop in your esophagus (esophageal perforation). This complication can be life threatening if left untreated.

Your doctor may use the following tests to help diagnose the condition:

Barium swallow test

A barium swallow test includes a series of X-rays of the esophagus. These X-rays are taken after you drink a special liquid containing the element barium. This contrast material temporarily coats the lining of your esophagus. This allows your doctor to see your throat more clearly.

Upper GI endoscopy

In an upper gastrointestinal (upper GI) endoscopy, your doctor will place an endoscope through your mouth and into your esophagus. An endoscope is a thin, flexible tube with an attached camera. It allows your doctor to examine your esophagus and upper intestinal tract.

Your doctor can use small tools attached to the endoscope to remove tissue from the esophagus. They’ll then analyze this sample of tissue to find the underlying cause of your esophageal stricture.

During an endoscopic ultrasound (EUS), ultrasound imaging is used during the endoscopy procedure. This can help your doctor see the area they’re examining, and help them locate tissue samples for analysis.

Esophageal pH monitoring

This test measures the amount of stomach acid that enters your esophagus. It’s often used to help diagnose GERD.

Your doctor will insert a small tube through your nose into your esophagus. The tube is usually left in your esophagus for at least 24 hours. Or, your doctor will use an endoscope to place a small wireless device inside your esophagus to collect measurements.

Treatment for benign esophageal stricture varies depending on the severity and underlying cause.

Esophageal dilation

Esophageal dilation, or stretching, is the preferred option in most cases. Sedation or general anaesthesia is typically used to keep you comfortable during the procedure.

Your doctor will insert an endoscope through your mouth into your esophagus. Once they see the strictured area, they’ll place a dilator into the esophagus.

There are several types of dilators, used for different purposes. A balloon dilator is a long, thin tube with a small balloon at the tip. By inflating the balloon, your doctor can expand the narrowed area in the esophagus.

To try to reduce inflammation and stop strictures from coming back, your doctor may inject steroid medication into the area.

Your doctor may need to repeat this procedure in the future to help open up your stricture further, or to prevent your esophagus from narrowing again.

Sometimes dilation can cause a tear in your esophageal lining. In rare cases, the procedure can cause a hole (perforation) in your esophagus.

Esophageal stent placement

The insertion of esophageal stents can provide relief from esophageal stricture. This procedure may be considered if your stricture doesn’t respond to other treatments.

A stent is a thin tube made of plastic, expandable metal, or a flexible mesh material. Esophageal stents can help keep a blocked esophagus open so you can swallow food and liquids. Your esophagus can also heal in a more open position while the stent holds it in place.

You’ll receive sedation or general anesthesia for the procedure. Your doctor will use an endoscope to guide the stent into place.

The stent is usually temporary, giving your esophagus time to heal in an open position. In around 4 to 8 weeks, your doctor will remove the stent.

Diet and lifestyle

Making certain adjustments to your diet and lifestyle can effectively manage GERD, which is the primary cause of benign esophageal stricture. These changes can include:

  • using pillows or wedge cushions to elevate your upper body when sleeping, to prevent stomach acid from flowing back up into your esophagus
  • losing weight, if overweight or obesity is contributing to GERD
  • eating smaller meals throughout the day
  • not eating for 3 hours before bedtime
  • quitting smoking, if you smoke
  • limiting the amount of alcohol you consume, if you drink

You should also try to limit foods that may cause acid reflux, such as:

  • spicy foods
  • fatty foods
  • carbonated beverages
  • chocolate
  • coffee
  • tomato-based foods
  • acidic foods, such as citrus fruits

Medication

Medications can also be an important part of your treatment plan.

A group of acid-blocking drugs, known as proton pump inhibitors (PPIs), are considered the most effective medications for managing the effects of GERD. These drugs block a type of receptor in your stomach, which reduces stomach acid production.

Your doctor may prescribe these medications for short-term relief to allow your stricture to heal. They may also recommend them for long-term treatment to prevent recurrence.

The PPIs used to control GERD include:

Other medications may also be effective for treating GERD and reducing your risk of esophageal stricture. They include:

  • antacids, which provide short-term relief by neutralizing acids in the stomach
  • sucralfate (Carafate), which coats the esophagus and stomach to protect them from acidic stomach juices
  • H2 blockers, such as famotidine (Pepcid AC, Zantac 360), which lower the secretion of acid

Surgery

Your doctor may recommend surgery if other treatments are ineffective. A surgical procedure can tighten your LES and help prevent GERD symptoms.

Treatment can correct benign esophageal stricture and help relieve the associated symptoms. However, the condition can occur again. Among the people who undergo esophageal dilation, 10% to 30% will need another dilation in the future.

You may need to take medication throughout your lifetime to control GERD and reduce your risk of developing another esophageal stricture.

You can help prevent benign esophageal stricture by avoiding substances that can damage your esophagus. Protect your children by keeping all corrosive household substances out of their reach.

Managing symptoms of GERD can also greatly reduce your risk for esophageal stricture. Follow your doctor’s instructions regarding dietary and lifestyle choices that can minimize the backup of acid into your esophagus. It’s also important to make sure you take all medications as prescribed to control symptoms of GERD.